Chapter 26

Fig. 339.—Nélaton Method.

Heuter Method.—The cheek flaps are cut from the cheeks, as shown inFig. 340, leaving intact a triangular piece of skin with the object of giving support to the new nose. The inner and upper borders of the two flaps were stitched to the rim of this triangle, and then along the median line. The flaps are not made to include the periosteum, as in Nélaton’s method. The results thus obtained are not equal to the latter’s procedure.

Fig. 340.—Heuter Method.

Bürow Method.—The cheek flaps are made as inFig. 341. The projection intended for the subseptum is an elongated strip at the inferior border and inner angle of the left flap.

The shaded triangles at either extremity of the outer incisions show the removal of the skin at these points, to facilitate sliding of the flaps, adding, however, to theextent of cicatricial contraction upon final healing, with the resultant flattening of the new nose. The lobular prominence takes an upward position eventually, and altogether the extensive secondary wounds and the effect of their behavior does not warrant the use of this method.

Fig. 341.—Bürow Method.

Szymanowski Method.—His method is an improvement on that of Bürow. The flaps, inclusive of considerable cellular tissue, are fashioned inFig. 342, except under the two narrow extension flaps, which are to be utilized in building up the subseptum. Their raw surfaces are sutured together with silk. The flaps are united along the median line.

If the tissue from the cheeks do not permit of free sliding forward of the flaps, further incisions shown by the dotted lines over each malar prominence are made. The skin of the shaded irregular areas on either side is removed, as in the Bürow method.

Fig. 342.—Szymanowski Method.

Serre Method.—The flaps are made to either side of the remains of the old nose, each leaving its pedicle about one fourth inch below the inner canthus of the eye. The flaps were cut rather obliquely, their bases extending somewhat below the nasal orifices. The remaining skin of the latter was dissected downward and folded down upon the median third of the lip. If cut in two sections their inner borders were sutured so that their raw surfaces faced each other. The object of the latter step was to form the subseptum, according to Lisfranc. The sections of skin lying with their bases on a level with the nasal orifices were dissected downward and unitedin the median line to assist in forming the end of the nose. All along the borders of the old nose were also dissected up where possible and folded inward, so that their raw surfaces would adhere to the new dorsum of the nose, and thus give it stability and form. These pieces of skin were united at the median line when possible.

The cheek flaps with indented bases were now brought forward and united, as shown inFig. 343. The skin of the cheeks was dissected up to the extent of the dotted line in the former illustration, and when necessary two lower curved incisions were made to permit of free sliding. The skin of the cheeks was retained by three sutures at either side, as shown inFig. 344. The subseptum may be made at the same sitting, or at a later operation.

Fig. 343.Fig. 344.Serre Method.

Fig. 343.Fig. 344.

Serre Method.

Syme Method.—The procedure is very like that of Heuter, except that the somewhat curved line making the inner borders of the flaps extended over the root of the old nose. The lower ends or bases of the two cheek flaps were stitched around and to the orifice to form the end of the nose, rubber tubes being used to form the nostrils, where they were retained until healing was complete.

Blasius Method.—He forms the cheek flaps in triangular form, including all of the tissue making up the buccalcavity. The outer or cheek incision is made through all of the tissue and extends to a point corresponding to a point a given distance beyond the angle of the mouth. The inner incision is made from a point just below the angle of the ala downward and through the thickness of the lip. A third incision unites the angle of the mouth with the outer incision. Both cheek flaps are made alike, each remaining attached along all of the remains of the old nose. They are now raised upward and inward, with their mucosa facing outward, and united along the median line. The raw cheek borders are now brought forward and held in place by suturing them at either side to the remaining rectangular flap of the upper lip. The formation of the subseptum is left for a second sitting. This method is not only too extensive, but too disfiguring to make its employment practicable. The mucous membrane would, of course, in time take on the function and appearance of skin, but the shape of the mouth never assumes a normal form, especially since there is quite a loss of the vermilion border at either side which is raised upward with the cheek flaps to assist in forming the base of the nose.

Maisonneuve Method.—Where there is more or less occlusion of the nares and yet an integumentary covering corresponding to the nose, as it might rarely be in congenital cases, Maisonneuve utilizes the sliding flap method to overcome the abnormality. In the case presented, the nasal orifices were hardly three sixty-fourths of an inch in diameter and about one inch apart. The correction was accomplished as follows, and shown inFig. 345: An incision was made transversely outward from each nostril, then two converging incisions were made from both nares downward, meeting at the vermilion border of the lip in the form of a V, which were made to include the whole thickness of the lip. This flap was brought upward to form the subseptum. The skin to form the nasal lobule was now slid forward from either end of theincision and the subseptum sutured in place. Rubber tubes were employed to keep the nares distended and permit of the wings of the nose to form.

The defect in the upper lip was brought together as in a median harelip operation, the parts appearing after operation as illustrated inFig. 346.

Fig. 345.Fig. 346.Maisonneuve Method.

Fig. 345.Fig. 346.

Maisonneuve Method.

In this classification of total rhinoplasty the skin flap is taken from another part of the body and not from the face. The integument of the arm is usually employed, the pedicle remaining intact until the flap has healed into place.

The method has been accredited to the Italian author-surgeon Tagliacozzi, but it was practiced long before his time; yet he was the first to fully describe the steps of the successful operation. It has been referred to quite fully under skin grafting.

The flap having an attached pedicle is cut from the entire thickness of the skin of the arm. The free end of the flap is sutured to the freshened borders of the oldnose, and the arm is held in place until union has been established, when the pedicle is cut. There are no special advantages in this method, since the outcome is no better than that obtained with the Indian method; at best the result is merely the curtain of skin covering the defect, with the one thing in its favor—the avoidance of the frontal scar. Against this is the great discomfort the patient must suffer in having his arm retained in the necessary position to prevent movement and strain on the flap, to which may be added the danger of embolism occasioned by freeing the arm at the time the pedicle is cut. There is also difficulty of properly dressing the wounds, owing to the constrained position which consequently invite sepsis and imperfect healing. Hence, for total rhinoplasty, this method may be termed unsatisfactory; yet for certain partial rhinoplastic results it supersedes all other methods, as will be hereinafter shown.

To make the flap a pattern is laid upon the skin, from which it is to be made; it should be one third larger than the actual size of flap needed, to allow for contraction. The incisions should go through the entire thickness of the skin, leaving an attachment or pedicle, what in this case would be the part of the flap intended for the base of the nose, and directly opposite to those described heretofore.

The flap may be sutured in place immediately after the cutting, or it may be allowed to remain upon the arm until contraction has taken place in the flap, or the flap may first be modeled into nose shape and then sutured upon the freshened margins of the old nose.

The arm must in any of these methods be held in place during the days required to have the flap heal or unite with the facial tissue. The various operators have devised means to accomplish this. There is the linen network of bandages of Tagliacozzi, the harness of Berger, the starched linen and book-board affair of Sedillot, theone-piece suit of Lalenzowski, the leather sleeve and helmet of Graefe and Delpech and many others.

Having determined upon the method to be followed in securing the flap, the surgeon is advised to consider such apparatus as he may be able to procure to retain the parts, or to use his own ingenuity to construct one of plaster-of-Paris bandages to meet the requirements of the case at not only less expense, but with greater comfort to the patient. At best, any apparatus employed will do little to overcome the agony of the retained member, which must be held in position.

Various operators give this period between six and twenty days. The apparatus should be so constructed that dressings can be easily made without discomfort to the patient, and without doing damage to the parts, and also to expose the face of the patient as much as possible. The various operations employed to perform total rhinoplasty by the Italian method may now be considered.

Tagliacozzi Method.—This surgeon resorted to four steps to accomplish his operations, which were:

I. Massage of or stretching the skin of the part from which the flap is to be made.

II. Cutting the flap, and allowing the same to cicatrize.

III. Freshening the flap and suturing in place, and use of apparatus.

IV. Cutting the pedicle and making the subseptum.

The various details of these steps should be considered here, since the methods are practically the same for all other operations of this kind, except in certain particulars as to time and mode of procedure.

I. Massaging the tissue of the arm to render it supple. This is of some consequence, in some cases, where the skin is tense, but requires no especial description.

II. He then compressed a fold of the skin with a large forceps at the lower half of the biceps. Upon opening these forceps he forced a bistoury under the skin foldand cut down toward the elbow-joint a distance sufficient to form a flap. This gave him a piece of raised skin, attached at either end, double the size of that required to make the nose. Under this he introduced linen mesh dressings in the form of a seton, with the object of irritating the skin to encourage the circulation, and render it thicker by consequent suppurations and granulations. This was continued for fifteen days, when the skin was detached at its upper end, leaving it attached by the lower or wider pedicle intended for the base of the nose. The flap was now turned down and both flap and wound were allowed to cicatrize.

III. When the flap had become dry he fitted the linen bandage apparatus to retain the arm. Then the borders of the old nose were freshened. Thereafter he cut a paper pattern as a model for the new nose, upon which the margins and shape of the flap were cut. The flap was finally sutured in place, and the apparatus was tightened to prevent movement of the parts.

IV. After twenty days he cut the pedicle. The latter was then cut into, to divide it in three parts, which he formed into the subseptum and nasal wings, which were sutured in place, metal tubes being employed to keep the nares open.

Dieffenbach Method.—This surgeon followed seven steps to complete the operation, as follows:

I. The pattern of the new nose, cut one third larger, is fixed upon the skin of the arm, with the basic pedicle just above the fold of the elbow. Skin is now raised sufficiently to permit of its being incised, the incisions being made laterally, as shown in the dark lines inFig. 347.

This gives a triangular flap, the apex lying upon the biceps and having two adherent pedicles at apex and base.

The base is now incised at one angle, transversely and again vertically, as shown. This incision liberates the part of the flap intended for one of the ala of the nose.

II. Diachylon plasters are placed under the flap tocontract the arm wound immediately the bleeding has been arrested. The free angle of the base of the flap is now turned inward and under the attached part of the flap, as inFig. 348, so that its margin protrudes from the other lateral incision, and its skin surface lying above the plaster. The edges of the flap are now stitched together, and the flap is allowed to lie cushionlike upon itself while the arm wound heals. This requires about six weeks.

Fig. 347.Fig. 348.Fig. 349.Dieffenbach Arm-flap Method.

Fig. 347.Fig. 348.Fig. 349.

Dieffenbach Arm-flap Method.

III. The holding of the flap cushion in place by the use of splints of leather held in place by three needles. The latter are moved about, as the shape of the cushion becomes modeled, about every three weeks. The process ends when cicatrization of the flap or the newly formed nose has been accomplished, shown by firmness and contour.

IV. The margins of the old nose are freshened; the lateral incisions extend to the root of the nose, wherethey are united with an upward convex incision. The skin is well raised, gutterlike, from the deeper tissue, to assure of the best vascularity.

V. The upper or apex pedicle of the flap on the arm is cut (seeFig. 349), and the thickened roll of skin, or what may now be termed the new nose, is turned down toward the elbow. It is divided along the line where the two margins of skin had been sutured; in other words, it is laid open longitudinally.

VI. The nose thus prepared is brought into place before the freshened margins of the old nose and is sutured into place beginning at the root before the sides are coapted.

VII. At the end of fifteen days the pedicle attaching the nose to the arm is severed, the angle for the wing being cut slightly larger than that of the other side, which by this time has, of course, undergone full contraction. The subseptum is made out of the square projection folded upon itself, raw surfaces facing, and is brought into place by suturing it into an incision made in the lip at the required point.

Graefe Method.—This surgeon devotes six steps to his operation, as follows:

I. The borders of the old nose are freshened.

II. Sutures are passed through the raised skin of the borders of the old nose.

III. The flap is cut from the arm after a pattern made one fourth larger than the new nose required, leaving it attached by the small pedicle intended for the subseptum.

IV. The sutures where required are now passed through the flap, having already been placed through the old nasal borders and left untied. The forearm is drawn against the forehead and the arm is fixed in place with the retention apparatus. The sutures are now tied. They are allowed to remain in about four or five days, not long enough to irritate.

V. About the tenth day the head apparatus is removed and the pedicle of the arm flap is divided. The arm may now be carefully lowered to its normal position.

VI. The subseptum is not formed from the free end of the attached flap for several weeks. It is then divided by two parallel incisions directed outward. The septal section is folded upon itself, and inserted and sutured in place into an incision made into the upper lip.

Szymanowski Method.—This author advises making the base of the flap sufficiently wide, and of the form shown inFig. 350, to permit of the three sections of skin of this part of the flap to be folded upon themselves before being sutured in place at the base of the nose, so as to form lined nares and a thickened and supportative subseptum.

Fig. 350.—Szymanowski Method.

Fabrizi Method.—This author utilized the immediate method of flap fixation, but makes his flap of triangular form from the inner and upper skin of the forearm.

The transverse base is made to lie one half inch below the radio-ulnar space. The flap should be about three inches long and of about the same width. It is cut while the forearm is relaxed; bleeding is controlled by gentle pressure. In the meantime the cicatricial tissue of the old nose margins has been removed and the skin freshened to receive the flap.

To approximate the parts, the hand is laid palm down upon the shoulder; the resultant position of the arm and forearm are retained by bandages. The parts are now sutured. On the thirteenth day the line of division istraced out upon the arm with nitrate of silver, at the same time giving the flap somewhat the form required to give the nose its contour.

The next day the pedicle is cut and the arm is brought back into its normal position. With the division of the pedicle he advises including a portion of the aponeurosis and a few fibers of the supinator longus muscle.

The flap is allowed to remain free at its base until contraction and cicatrization have been established, when the subseptum and wings are made.

The position of the arm and the attached flap at the root of the nose is shown inFig. 351.

He advises, when possible, to dissect up a flap of the cartilage of the old septum, letting it adhere at its lower border and turning it from below upward with the skin which covers it to form the subseptum. This will help to hold up the point of the nose firmly (an important matter because it is at this point that all noses constructed of skin flaps alone sink down for the want of suitable prop of tissue).

This cartilaginous flap he held in place with two pins thrust through the latter and the skin flap proper, and held them in place with a figure twist of silk. He removed the needles about the sixth day.

Fig. 351.—Fabrizi Method.

Steinthal Method.—This authority made the flap for the nose from the skin over the sternum, proceeding as follows:

“From the sternum I cut a flap of skin and periosteum in the form of a tongue whose lower base was five centimeters wide, and the summit forming the pedicle three centimeters wide; its length was twelve centimeters.

“I could have taken away with this flap some of the costal cartilage to utilize in making the wings of the new nose.

“I dissected up this flap and closed the wound over the sternum with sutures. The flap was then stitched to the forearm by its base into an incision of appropriate length made near the radius. (SeeFig. 352.)The arm was properly fastened in a plaster apparatus and the flap enveloped in a dressing of borated vaselin. The forearm was held in front of the breast, an attitude easily retained. Twelve days later I cut the pedicle.

“I let a few days pass by, and then stitched the pedicle end of the flap to the root of the nose. A new plaster apparatus was put in a suitable position. The hand was placed on the forehead.

“Ten days after, I detached the flap from the arm and reformed the nose with the flap, which hung down like an apron. It is necessary to have a flap sufficiently long to fold in for the nostrils. I used bronze aluminum wires for all the sutures.”

The position of the hand while the flap was healing to the root of the old nose and the slight twist of the flap is shown inFig. 353.

Fig. 352.Fig. 353.Steinthal Method.

Fig. 352.Fig. 353.

Steinthal Method.

To overcome the consequent cicatricial contraction and falling in of the flap used to make the new nose by either of the three grand methods given, various surgeons have resorted to lining the flap with skin flaps, bringing their raw surfaces together so that the nose actually received in this way an integumentary lining.

While this had the tendency to thicken the new nose, it did not give the support necessary to it, especially at the lower third, and the lobule, at first quite satisfactory, resulted only in the appearance and form of a small tubercule of tissue, with a decided saddle effect above it. This combined method did overcome, however, the slow process of cicatrization, and its accompanying suppuration.

The raw surfaces of the two flaps, if properly brought together, healed upon themselves readily, as has been referred to in the lining or doubling in of the basal sections to form the nostrils and subseptum.

The method of lining the nasal flap in this manner is never sufficient to give a satisfactory result in total rhinoplastic cases, but may be of great service in restoring parts of the nose, as will be shown later.

The requirement is that of support, whether it be organic or inorganic, and these methods will be considered presently.

Volkmann Method.—This surgeon fashioned the frontal flap as shown inFig. 354. This resulted in leaving a triangle of skin at the root of the nose, which he dissected up, down, to and inclusive of the periosteum, and turned downward so that its raw surface faced upward, as inFig. 355. The flap was sutured into place to retain it.

The frontal flap was brought down, so that the two raw surfaces came together.

This method overcame the contraction of the flap over the nasal bridge or superior third of the new nose, and an excellent adhesion of that part of the flap to the denuded bone and flap resulted, but the same faults about the base were not mitigated.

Fig. 354.Fig. 355.Volkmann Method.

Fig. 354.Fig. 355.

Volkmann Method.

Keegan Method.—The frontal flap method of Keegan has been referred to. For the lining of the upper nose he cuts two flaps from the skin above the old nasal orifice, as shown inFig. 356, which he turns down, raw surfaces out. This gave a lining to either side of the median line; the skin remaining intact between the two flaps gave additional prominence and support to the upper third of the new nose.

Fig. 356.—Keegan Method.

Verneuil Method.—Contrariwise to the methods just given, Verneuil, after cutting out the frontal flap, cuts the flap from the remaining sides of the old nose somewhat involving the skin of the cheeks, as inFig. 357. This done, the frontal flap is simplyturned down, raw surface out, and the cheek flaps are slid over it, bringing the raw surfaces together. The inner borders of the flaps were sutured in the median line, as shown inFig. 358. The base of the nose is made from the frontal flap by any of the methods already given.

Fig. 357.Fig. 358.Verneuil Method.

Fig. 357.Fig. 358.

Verneuil Method.

Thiersch Method.—The frontal flap is cut from the skin of the forehead in the shape shown inFig. 359. Then two quadrilateral flaps are raised from the cheeks, as also illustrated. These are made wide enough that, when they were brought together, their inner borders could be made to face each other. In this position they were sutured along the median line, so as to give a double-gun-barrel form to the nose, with a septal wall between.

From the lower border the nostrils were formed, giving to the new nose a normal appearance, the continuous septum curving downward to form the subseptum, the whole being sutured to the remains of the old nose.

The frontal flap was now brought down over it, the raw surfaces facing each other, and sutured in place, as shown inFig. 360. Later, Thiersch replanted the sides of the nose, to give it better contour, and attained a verysatisfactory result. The frontal wound was covered with skin grafts, but the cheek wounds were allowed to heal by granulation. The cicatrization of the latter was not sufficient to effect the lower eyelids nor the angles of the mouth.

Fig. 359.Fig. 360.Thiersch Method.

Fig. 359.Fig. 360.

Thiersch Method.

Helferich Method.—His is an ingenious application of the French method. Both flaps are cut from the cheeks; the lining flap was made from the left and the covering one from the right cheek. The shape of the flaps is shown inFig. 361.

The lining flap is stitched along the freshened margin of the right side of the nose. The flap should be wide enough to give convexity to the nose, as shown inFig. 362.

The covering or right flap, cut much larger, is now slid over this. It should be cut amply large to cover the flap just sutured in place. It is sutured on both sides of the nose to hold it in place, also at the inferior margin. The nose is lightly packed with iodoform gauze.

The pedicle of the right flap was cut after two and a half weeks and brought into place across the root of the nose, and sutured in place to give better contour to the part after freshening the skin about the left side of the nose at this point. He does not make a subseptum, but thinks the inferior base of the nose of sufficient size to hide the absence thereof.

The subseptum could, however, be readily made from the upper lip, as will be shown later.

Fig. 361.Fig. 362.Helferich Method.

Fig. 361.Fig. 362.

Helferich Method.

Sedillot Method.—This operation is particularly efficacious in giving a splendid subseptum and support of the point of the nose, but does not overcome the falling-in of the whole anterior line, so common with all Indian-flap methods. A flap one centimeter wide and extending downward almost to the vermilion border is cut from the thickness of the upper lip, not including the mucous membrane, however. It is turned upward, as shown inFig. 363.

The frontal flap is fashioned as shown, care being taken to cut a subseptal rectangle of greater length than usual, since it is intended to overlie the raw surface of the flap taken from the lip. It is rotated downward and sutured into place at both sides, and also to the lip flap, to assure of accurate union.

A lateral view of the nose as formed in this manner is shown inFig. 364.

The free end of the septal flap is fixed into the superior lobial wound with a harelip pin. The lobial wound is sutured as in ordinary harelip operations. This method is particularly valuable in total rhinoplasties involving the columna and alæ in conjunction with flaps obtained by the Italian method.

Fig. 363.—Anterior view.Fig. 364.—Side view.Sedillot Method.

Fig. 363.—Anterior view.Fig. 364.—Side view.

Sedillot Method.

Küster-Israel Method.—A flap was taken from the arm by the Italian method, which was sutured to the remains of the old nose so that its raw surface looked upward, not downward, as in the ordinary case.

The flap was made sufficiently large to permit of building the wings and subseptum. After it had healed into place the pedicle was cut, and a frontal flap was cut from the forehead to cover it.

An unusually large flap was required to do this, since it had to overcome the greater curvature already given and added to by the arm flap, necessitating an extensive secondary wound.

The reverse order of procedure would be the more advisable for this reason, and is resorted to by the following:

Berger Method.—This surgeon makes the lining flap from the forehead. The secondary wound is at once closed. A flap is then made from the arm by the Italian method, and brought into place before the one just made. It should be of sufficient size to allow of building the base of the nose, which is done not later than three weeks after the pedicle of the arm flap is severed, which may be done at any time between the eighth and the twelfth day.

All the precautions are used as already given in the description of the Italian method. The arm is held in the position shown inFig. 365.

Berger sutures the arm wound before bringing the flap into place upon the face to overcome the discomfort of suppuration to the patient.

The apparatus is fixed definitely after the patient has recovered from the anesthetic. Great care is exercised to prevent coryza from exposure. Dressings are made twice daily.

The pedicle is cut under local cocain anesthesia.

To make the subseptum and wings of the nose, the base of the flap is cut into three sections. The posterior surface is freshened and the parts are folded upon themselves and sutured into position.

Instead of employing rubber tubes, he resorts to a specially devised apparatus to retain two metal tubes in the nares, and at the same time make gentle pressure to the sides of the nose to mitigate the columna contraction. The latter is planted into a V-shaped incision made into the tissue of the upper lip at the proper place of attachment. The subseptum may be lined witha flap of mucosa dissected up from the floor of the inner nose.

For the wings of the nose, such tissue as may be of service to give them stability and structure is taken from the remains of the old nose.

Fig. 365.—Berger Method.

The apparatus just mentioned and shown inFig. 366is used from the very first day until total cicatrization has taken place, and even for a longer period to aid in shaping the entire nose and the tendency to collapse has been overcome.

Fig. 366.—Berger Retention Apparatus.

Szymanowski Method.—A frontal flap, divided along the median line and shaped as outlined inFig. 367, is made from the forehead.

Two triangular flaps are then raised from either side, and including the angle of the nose as shown. The divided frontal flap is now brought down in such manner that their raw surfaces meet, thus forming a vertical septum. The margins are united by suture, and the lowerends are fixed into a wound made for the purpose at the base of the nose, as shown inFig. 368, to form the new subseptum.

The lateral triangular flaps are dissected up so that they can be readily slid forward toward the median line. Their inner freshened margins are sutured to the raw edge of the septum just made, and to themselves. The objection here is that there is a liability of considerable contraction of these lateral flaps, with a tendency to fall in and drag with them the new septum; and again, in total restorations, the upper third of the nose is only partially covered, and necessitates later upbuilding. The author finds difficulty in making the four margins thus brought together unite evenly throughout, and that a vertical contraction is caused by the cicatrization of the median marginal wound.

Fig. 367.—First Step.Fig. 368.—Disposition of frontal flaps.Szymanowski Method.

Fig. 367.—First Step.

Fig. 368.—Disposition of frontal flaps.

Szymanowski Method.

Goris Method.—The operation is performed as follows, having given very good results, according to the author:

I. The frontal flap is divided lengthwise so that its raw surfaces face each other. The resulting fold, representing the bridge of the nose, is held in place by catgut suture.

II. The skin to make the wings of the nose is folded in, as in the Langenbeck method.

III. A flap, half the thickness of the upper lip is brought up to form the new subseptum.

IV. Dissection and turning down the triangular flap of skin which surmounts the orifices of the old nose, and making it serve to line the lower part of the frontal flap.

V. Suturing the frontal flap thus modeled into two grooves made into the margins of the old nose along both sides to its base.

It soon became evident to the rhinoplastic surgeon that without some support to the flap or flaps used forthe construction of the new nose all of the preceding methods, as far as æsthetic results were concerned, were useless. Truly, the deformity lost its hideous appearance to a great extent, but the general results obtained hardly warranted a patient to undergo restorative operations of the nose. In fact, many surgeons advised against total rhinoplasty when practically all of the old nose was lost.

Langenbeck says “that total rhinoplasty, or even operation as to repair partial loss of the nose by the use of soft flaps, should not be undertaken. It is better to rely upon some prothesis.”

All that could be expected of utilizing the flap and making it heal into place had been accomplished up to about the year 1879. Thereafter many surgeons proceeded to evolve and use some kind of intranasal prothesis made of various inorganic materials. It may be stated, however, that Rousset in 1828 wrote: “Perhaps some day surgeons will give whatever shape they desire to the reconstructed nose. Then a frame of gold or silver, cleverly shaped and solidly fixed in the nose, will give the patient, at his own option, a Roman or Carthaginian nose, and to the ladies a choice of a roguish type, and to our Sultans a nose a la Roxelane.”

But it was after 1878 that such prothesis came into use, and these were at first made so that they might be removed at night and be replaced in the morning.

The intranasal supports were made of all kinds of material, such as gutta percha, gold plates, leaden devices, amber, silver, porcelain, celluloid, aluminum, platinum, etc.

With all due respect to the ingenuity of these inventions, especially that of Martin, which was made of platinum in the form of a St. Andrew’s cross, having at the four ends sharp pins which were driven and fixed into the skeleton of the nose, the use of these protheses resulted in nothing but failure.

The movable devices were a source of irritation and pressure, and could not overcome the consequent contraction of the flaps whether placed below a single flap or between two flaps, and the fixed protheses of whatever form or material caused so much pressure that gangrene resulted, and they had to be removed sooner or later.

Before the discovery of Gersuny, the author had many occasions to utilize such movable protheses in the correction of saddle noses. These were generally made of a silver shell, gutta percha, and later of decalcified bone, as advised by Senn. The former remained in place from six months to two and a half years, and then were thrown off or had to be removed because of irritation. The bone chips soon became absorbed, leaving the nose as before, or a thin median strip that became broken with the least violence, and then was absorbed.

In several cases where other surgeons had resorted to such protheses, the author was called upon at a later period to remove them.

While the immediate result is very gratifying, the ultimate result is worse than useless, since in the elimination of the foreign body the flap of the nose was married by cicatrices that added still further to the contraction and falling-in of the nose.

Some other method had to be devised, and organic supports became known. These organic protheses were made of the tissue in the near vicinity of the flap, and at first formed a part thereof. The earlier method included only the periosteum; later bone and periosteum were added to the flap to give it shape and support, and lastly cartilage was employed for the purpose.

Of the methods employing only the periosteum, it maybe said that what the surgeon expected of this membrane—namely, the springing up of bone cells—did not take place; at least, not to the extent desired. The very best to be attained was a thickening of flap in the membrane, but not sufficient to add necessary support to the nose.

The inclusion of the periosteum-lined flap was soon abandoned, and recourse was had to such bone additions to the flaps as could be obtained from the vicinity of the nose.

The bone was removed with its periosteum, adherent or nonadherent to the flap, as will be shown by the methods described hereafter.

Both single and combined flap methods are employed as might be expected, following the procedures of the Indian, French, or Italian schools. The greatest credit for the methods herein involved belongs to the surgeons of Germany.

The earliest operation on these lines was that of König, who published his first successes in 1886.

König Method.—Extending upward from the root of the old nose, a flap is outlined in vertical ending at the hair line of the scalp, as shown inFig. 369.

This flap was made about one centimeter wide, and is made to include the skin and periosteum. With the chisel a thin strip of bone is raised from the frontal bone to nearly the full length and width of the flap, making it an osteoperiostitic cutaneous section attached by its pedicle at the root of the nose.

This flap is brought down with bony surface outward, and the distal or skin end is fixed by suture into the upper lip at the point of the intersection of the subseptum.

Any of the soft parts of the old nose remaining are now dissected up toward the median line, and are foldedupward and inward and sutured by their freshened margins to this median flap.

An Indian flap in oblique direction and of the form shown is cut from the skin of the forehead and rotated down into position before the bone-lined flap, and sutured into place.

He advises not to include the periosteum in the flap making up the subseptum, as it is likely to interfere with respiration. In fact, he deems it best to make the tegumentary flap sufficiently long to build the bone of the nose, doubling the raw edges upon themselves with a celluloid tube apparatus that may be removed for cleansing, and be kept in place long enough to give contour to the nares.

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