Fig. 404.—Second step.Fig. 405.—Position nasal bone occupies.Ollier Method.
Fig. 404.—Second step.Fig. 405.—Position nasal bone occupies.Ollier Method.
Fig. 404.—Second step.
Fig. 405.—Position nasal bone occupies.
Ollier Method.
Langenbeck Method.—A median incision is made through the remaining skin of the old nose, dividing it into halves. The incisions about the base and the shape of flap to be brought down from the forehead are shown inFig. 406.
The skin over the nose is dissected up, moving toward the cheek, exposing the bony frame of the nose.
From the lower border of the pyriform aperture two elongated triangular plates of bone are made, beingattached posteriorly to superior maxillary bones. They should be made about one sixth inch wide.
By their subsequent displacement they are made to lie antero-posteriorly. With a saw the nasal bones are separated from their maxillary connection from below upward, making a median bone plate, which is raised with a levator to the height desired for the new nasal bridge, remaining attached to the frontal bone, as shown inFig. 407.
A frontal flap is taken from the forehead and sutured to the freshened raw margins of the lateral flaps.
The bone plates are fastened to each side of the frontal flap by suture.
The nasal base is preferably made of the tissue remaining of the old nose, as depicted, to prevent closure of the nostrils, the only difficulty being to keep the poorly nourished tissue from dying. When used the raw surface is brought in contact with that of the frontal flap.
The objection in this case is that the median third anterior line usually falls in rapidly, leaving the nose dished or saddled, and unless there be sufficient tissue to construct the base, the objections so often referred to heretofore will occur.
Fig. 406.—First step.Fig. 407.—Showing separation and elevation of nose flaps.Langenbeck Method.
Fig. 406.—First step.Fig. 407.—Showing separation and elevation of nose flaps.Langenbeck Method.
Fig. 406.—First step.
Fig. 407.—Showing separation and elevation of nose flaps.
Langenbeck Method.
Ch. Nélaton Method.—This author uses an osteo-cutaneous flap taken from the forehead. The shape of the latter is shown inFig. 408.
The lateral incisions are to be made the width of a finger from the margins of the old nose, extending upward in curved fashion through the inner edge of the eyebrows and meeting at a point on the forehead, becoming slightly oblique near the border of the hair.
The flap is dissected up from the borders inward, including the periosteum, leaving a strip of bony attachment at the median line.
The dissected sides of the flap are held up by an assistant while the operator proceeds to chisel a thin bonyplate from the frontal. The bony plate ends just above the root of the nose.
The dissection is now carried on downward until the bones proper of the nose appear, and latterly, so that the saw does not injure the soft parts, and to act as a guide for the course of the latter.
The position of the flap and the saw in position is shown inFig. 409.
Fig. 408.—First step.Fig. 409.—Making lower nasal flap section.Nélaton Method.
Fig. 408.—First step.Fig. 409.—Making lower nasal flap section.Nélaton Method.
Fig. 408.—First step.
Fig. 409.—Making lower nasal flap section.
Nélaton Method.
The saw is made to sever the nasal bones from the apophyses of the superior maxillary. The blade follows a line starting one centimeter anterior to the anterior and superior nasal spine, and is directed downward toward the second molar, not going entirely through the apophyses.
The latter are broken with the chisel in such way that some of the bony border lies in contact with the nasal process of the superior maxillary.
This fracturing is made as the flap is still further brought down, as inFig. 410.
The flap is now so adjusted that its median bone-lined section will form the median third of the nose, the base being made by folding the flap upon itself, as shown inFig. 411.
Fig. 410.—Forming base of nose.Fig. 411.—Ultimate disposition of entire flap.Nélaton Method.
Fig. 410.—Forming base of nose.Fig. 411.—Ultimate disposition of entire flap.Nélaton Method.
Fig. 410.—Forming base of nose.
Fig. 411.—Ultimate disposition of entire flap.
Nélaton Method.
The raw surfaces are sutured at their point of coaptation, laterally, and to the margins of the genian flaps.
The frontal wound is brought together by suture as closely as possible, and Thiersch grafts are employed to close any wound still remaining.
The objections to this operation is that of all bone-plate flaps. A flap containing a cartilaginous supporttaken from the eighth costal cartilage, as previously described, would undoubtedly give the best results.
The defect being at a distance from the forehead, the employment of frontal flaps for the restoration of the lobule and alæ are to be eliminated; furthermore, such methods would involve the incision and dissection of the healthy skin of the nose to no advantage but disfigurement, and possible further loss of the organ.
The results with autoplasties about this part of the nose are usually excellent, and particularly gratifying are those obtained with the Italian method, in which the flap is made from the skin of the forearm.
French methods involving large nasogenian flaps are not to be used because of their consequent retraction and cicatrization of the cheeks. Small lining nasogenian flaps may be utilized where necessary, since they cause little scarring.
If the loss of tissue is very small, the flaps to reform the parts may be taken from the nasal skin and the septum be made of a flap from the upper lip. Both such secondary wounds could be drawn together by suture, leaving slight linear scars. Operations of this nature will be described separately later. Some of the methods referred to might be combined for small defects of this nature.
Defects of larger extent may be corrected as follows:
Küster Method.—A flap of considerable size is outlined on the skin of the arm and cut laterally, leaving it attached at both ends in bridge fashion.
Gauze dressings are inserted under the flap. Several days later the superior pedicle is severed and the flap is sutured to the freshened margin of the nose. An application of borated vaselin on gauze is used as the dressing.The arm is held in position by a proper apparatus, a plaster-of-Paris fixture being used by the author.
Six days later the brachial plexus is divided to half its width, and totally divided three days thereafter.
Fifteen days later the free border of the flap is divided into three sections, the median one being made narrowest. The outer small flaps thus made are sutured to the remaining wings of the nose.
Five days later the septum is formed of the remaining unattached flap, which is sutured to the stump of the old septum. It is not folded upon itself, but allowed to heal by cicatrization.
Eight days later minor operations are performed to reduce the exuberant portions of the side flaps.
Berger Method.—This author makes a flap of the skin above the border of the nose, which he turns down, raw surface outward, upon which he immediately brings a flap from the arm. The object of the lining is to give stability to the base of the new nose as well as to prevent curling and contraction of the rims of the nostrils.
Bayer-Payr Method.—Two flaps two and a half centimeters wide are cut from the nasolabial furrow, extending down to the lower border of the inferior maxillary bone, as shown inFig. 412.
The flaps are dissected up and brought forward and upward, their raw surfaces meeting in the median line, where they are sutured upon one another to the extent of three centimeters, as shown inFig. 413.
The nasolabial wounds are brought together by suture except for a small triangular space near each pedicle, which are allowed to heal by granulation.
The superior borders of the flaps were then united by suture to the freshened margins of the nose, which have been prepared as shown in the illustration.
The septal ends of the two flaps are likewise sutured to the stump of the old septum.
The raw or outer surfaces of the flaps are to be covered with Thiersch grafts when ready for them, though this may not be necessary with small flaps.
The pedicles of the flaps are not cut until the end of the fourth week, when the fresh ends may be sutured to freshened surfaces of the wings made to receive them.
The disposition of the parts at this period is shown inFig. 414.
Fig. 412.—First step.Fig. 413.—Disposition of flaps.Fig. 414.—Ultimate placing of pedicles after division.Bayer-Payr Method.
Fig. 412.—First step.Fig. 413.—Disposition of flaps.Fig. 414.—Ultimate placing of pedicles after division.Bayer-Payr Method.
Fig. 412.—First step.
Fig. 413.—Disposition of flaps.
Fig. 414.—Ultimate placing of pedicles after division.
Bayer-Payr Method.
Ch. Nélaton Method.—This author in cases of extensive destruction of the point of the nose advocates the lining of an Italian flap with skin flaps made in similar manner, as in the foregoing operation.
The lining flaps are taken from the nasogenian furrow, placed and sutured as just described, without twisting of their pedicles, and are sutured at the median line and at their free ends to the freshened septal stumps.
The Italian flap is placed over those two flaps immediately, or the Italian flap is first made to unite to the raw margin of the defect, and the two nasogenian flaps are made and employed at a later sitting by subplanting.
The Italian flap may be taken from the arm or forearm, this surgeon preferring the forearm. The attached flap and position of the hand on the forehead where it is retained with an apparatus for the required time is shown inFig. 415.
The adherent Italian flap and its subseptal addition and the outlines for the lining flaps are shown inFig. 416.
The secondary nasogenian wounds reduced by suture and the flaps so obtained are shown inFig. 417. The subseptal section of the Italian flap is raised toshow the disposition of the flap ends to form the new septum. The raised flap is brought down and sutured to the raw edges of the two septal flaps covering the median cicatrix, its own cicatrices falling within the rim of the nostrils.
Fig. 415.—Attachment of flap from forearm.Fig. 416.—Forearm flap in position and outline of lateral flaps.Fig. 417.—Disposition of lateral flaps.Ch. Nélaton Method.
Fig. 415.—Attachment of flap from forearm.Fig. 416.—Forearm flap in position and outline of lateral flaps.Fig. 417.—Disposition of lateral flaps.Ch. Nélaton Method.
Fig. 415.—Attachment of flap from forearm.
Fig. 416.—Forearm flap in position and outline of lateral flaps.
Fig. 417.—Disposition of lateral flaps.
Ch. Nélaton Method.
This surgeon advises in less severe losses of tissue to do without lining the Italian flap, but to make the latter large enough to be able to fold in enough of its base sections to line the nostrils to the extent of the inferior line of the mucosa. The flap should be cut one fourth longer than the nasal deformity.
This procedure also overcomes to a great extent the shrinking of the nasal orifices.
The pedicle of the flap is cut close to the arm at the end of two weeks. The subseptum may be made at once if the flap shows good nutrition, as evidenced by marked bleeding at the time of cutting away the bridge tissue.
The method of restoration of the wing or wings of the nose depends largely upon the extent of the tissue loss.
The use of the Hindu method is not advisable, since the flap must be made with a long pedicle, which involves the making of a large wound and predisposes to consequent large cicatrices, although many surgeons have resorted to the method. The author does not see any advantage with this method, even if the loss of tissue about the lobule is great.
The best results, both as to the primary and secondary wounds, are those obtained with the Italian method, and in extensive cases the use of a combined flap, wherein the lining flap is taken from the nasolabial furrow or just above it. This leaves a linear scar that does not disfigure the face, and assures of better contour than when a single integumentary flap is employed which, as has been so frequently mentioned, is liable to curl inward and contract in an upward direction, adding little to the area of lost tissue.
The ideal operations are those which include cartilaginous supports, which may be obtained from about the border of the deformity or from some remote place, as of the ear. The surgeon is hardly justified to use the remaining healthy tissue of the nose, unless the case is such that the secondary wound can be corrected, so as not to add scars to the face.
Small defects can be easily corrected by sliding flaps taken from the vicinity of the defect, whether they include cartilage or not, and by granulation or dissection and approximation of the skin, the secondary wound may be entirely closed. It is remarkable how little linearscars show about the nose when the lips of the wounds have been neatly brought together.
The author advocates the use of the continuous silk suture for this purpose, since it fulfills both the object of suture and splint and overcomes the corrugating effect, so often found with interrupted sutures; furthermore, a continuous suture is more easily withdrawn, and there is no danger of wounding the skin on removal, and the discomfort to the patient is greatly reduced.
From the foregoing descriptions of procedure, the surgeon has been sufficiently familiarized with such steps in rhinoplasty as are usually employed, and it would be a matter of constant repetition to rehearse these same steps for the following operations; therefore the author trusts the illustrations given will be sufficiently lucid to work from. All special features to be observed are given.
Denonvillier Method.—The secondary wounds made by the two methods here given may be allowed to heal by granulation or be covered with skin grafts, as heretofore described.
Fig. 418.—Making of flap. Pedicle anterior.Fig. 419.—Disposition of flap.Fig. 420.—Pedicle posterior.Fig. 421.—Disposition of flap.Denonvillier Method.
Fig. 418.—Making of flap. Pedicle anterior.Fig. 419.—Disposition of flap.Fig. 420.—Pedicle posterior.Fig. 421.—Disposition of flap.Denonvillier Method.
Fig. 418.—Making of flap. Pedicle anterior.
Fig. 419.—Disposition of flap.
Fig. 420.—Pedicle posterior.
Fig. 421.—Disposition of flap.
Denonvillier Method.
Mutter Method.—A skin flap is taken from the cheek and slid forward into the defect as shown.
Fig. 422.Fig. 423.Mutter Method.
Fig. 422.Fig. 423.Mutter Method.
Fig. 422.Fig. 423.
Mutter Method.
Von Langenbeck Method.—The skin flap is taken from the healthy side of the nose and brought into the defect by sliding.
The secondary wound is allowed to heal by granulation.
Fig. 424.Fig. 425.Von Langenbeck Method.
Fig. 424.Fig. 425.Von Langenbeck Method.
Fig. 424.Fig. 425.
Von Langenbeck Method.
Busch Method.—The same method as above is employed except that for the incisionA,C, which, upon dissection of the skin in triangleA,B,C, allows the closure of a larger defect than could be corrected with the lateral nasal flap alone (seeFig. 426).
Fig. 426.—Busch Method.
Fig. 426.—Busch Method.
Fig. 426.—Busch Method.
The following illustrations are similar to those given and involve only the skin in the flaps made, as shown.They are only of interest in portraying the position of the flaps and their pedicles.
Fig. 427.—Dieffenbach Method.Fig. 428.—Dupuytren Method.Fig. 429.—Fritz-Reich Method.
Fig. 427.—Dieffenbach Method.
Fig. 427.—Dieffenbach Method.
Fig. 427.—Dieffenbach Method.
Fig. 428.—Dupuytren Method.
Fig. 428.—Dupuytren Method.
Fig. 428.—Dupuytren Method.
Fig. 429.—Fritz-Reich Method.
Fig. 429.—Fritz-Reich Method.
Fig. 429.—Fritz-Reich Method.
Fig. 430.Fig. 431.Fig. 432.Fig. 433.Sedillot Method.
Fig. 430.Fig. 431.Fig. 432.Fig. 433.Sedillot Method.
Fig. 430.Fig. 431.Fig. 432.Fig. 433.
Sedillot Method.
Fig. 434.Fig. 435.Nélaton Method.
Fig. 434.Fig. 435.Nélaton Method.
Fig. 434.Fig. 435.
Nélaton Method.
In the Bonnet method the flap is taken from the entire thickness of the upper lip and by twisting is brought into the defect. The pedicle must be cut at a later sitting.
Fig. 436.Fig. 437.Bonnet Method.
Fig. 436.Fig. 437.Bonnet Method.
Fig. 436.Fig. 437.
Bonnet Method.
Weber Method.—The flap is made from half the thickness of the upper lip, as shown inFig. 438, and brought into the defect, as inFig. 439. The pedicle is cut later.
Fig. 438.Fig. 439.Weber Method.
Fig. 438.Fig. 439.Weber Method.
Fig. 438.Fig. 439.
Weber Method.
Thompson Method.—This author uses a lateral flap taken from the cheek, as shown inFig. 441, and lines it with a flap of mucosa dissected from the septum antero-posteriorly, as shown inFig. 440, disposing of the latter flap as shown. The raw surface meets the raw surface of the skin flap, as inFig. 442.
At a later sitting the two pedicles must be severed and adjusted by small minor operations.
Fig. 440.—Mucosa flap.
Fig. 440.—Mucosa flap.
Fig. 440.—Mucosa flap.
Fig. 441.Fig. 442.Thompson Method.
Fig. 441.Fig. 442.Thompson Method.
Fig. 441.Fig. 442.
Thompson Method.
Blandin Method.—The flap is made of the whole thickness of the lip. The pedicle is cut at a second sitting.
Fig. 443.Fig. 444.Blandin Method.
Fig. 443.Fig. 444.Blandin Method.
Fig. 443.Fig. 444.
Blandin Method.
Von Hacker Method.—This author adds a flap from the nasolabial region to line that taken from the healthy side of the nose, as shown in the Langenbeck method. There is little cicatrization here, and the result is excellent for defects of large area.
The procedure and shape of flaps as used are shown inFigs. 445 and 446.
Fig. 445.Fig. 446.Von Hacker Method.
Fig. 445.Fig. 446.Von Hacker Method.
Fig. 445.Fig. 446.
Von Hacker Method.
Kolle Method.—The author dissects away the flapE,A,Dwhen part of the mucosa and cartilaginous tissue remains, and where there is a loss, total or partial, of the alar rima, the transverse incisionEbeing made as long as required to overcome the defect by sliding, as inFig. 447.
The latter flap is freshened at its inferior border along the lineD, and a second or bordering flap of sufficient width to line and face the nostril is taken up from the upper lip, skin only, as shown in areaC.
The lateral or upper flap is now slid down to slightly overcome the loss of tissue and the flapCis brought upward by twisting slightly on its pedicle and sutured in place, as shown inFig. 448.
The secondary wound lying between the linesEandE’, occasioned by the sliding downward and leaving the triangular defectF, is allowed to heal by granulation. The lateral flap is fixed along the lineA.
Usually the pedicle of flapCneed not be cut, as it adjusts itself under primary union.
The secondary lip wound is closed at once by suture.The author has also used the inverted V incision of Dieffenbach, including the cartilage or part thereof that remains above the defect, and has moved this flap downward, suturing in Y fashion with good results.
Fig. 447.Fig. 448.Author’s Method.
Fig. 447.Fig. 448.Author’s Method.
Fig. 447.Fig. 448.
Author’s Method.
Denonvillier Method.—The operation is similar to that of Dieffenbach and the author’s modification just mentioned. Its advantage, as in the latter, is that the inferior border or nasal rim remains intact, and contains what cartilage remains above the defect. The shape of the incision is as shown inFig. 449.
The flapA,B,Cincludes the skin and such cartilage as can be used, while the rim below the lineB,Dretains its lower cicatricial border.
The flap is slid down until the defect has been overcome, and the resultant superior triangular wound is allowed to heal by granulation. The dissection of the flap is made down to the line including the skin or cartilage referred to. At the dotted lineB,Dthe whole thickness of the tissue except the overlying skin is involved.
Fig. 449.—Denonvillier Method.
Fig. 449.—Denonvillier Method.
Fig. 449.—Denonvillier Method.
Von Hacker Method.—The flapA,F,C, as shown inFig. 450, is cut from the entire thickness of the side of the nose attached by its posterior pedicleC.
This flap is moved downward, and its anterior border is sutured along the freshened lineA,B, as inFig. 451, leaving a triangular defect,A,F,C.
Two little triangular flaps of skin are dissected up, skin only, atD,E,CandH,G,C.
Next a rectangular flap,I,K,L,M, is dissected up from the cheek, as inFig. 452, including some areolar tissue.
The flap should be made sufficiently long, so that when folded over it will fit into the defect without tension, at the same time allowing for contraction.
This flap is sutured into the defect made by the making of the first flap, as shown.
The secondary wound of the cheek is brought together by suture, except for a small triangle near the pedicle to avoid its constriction.
Its raw surface is allowed to heal by granulation. The pedicle is severed in about fifteen days, and may be cut in triangular fashion to make it fit smoothly into the slight defect in the skin just posterior to it.
Fig. 450.Fig. 451.Fig. 452.Von Hacker Method.
Fig. 450.Fig. 451.Fig. 452.Von Hacker Method.
Fig. 450.Fig. 451.Fig. 452.
Von Hacker Method.
König Method.—In this novel method a flap somewhat of the form of the defect is taken from about theentire thickness of the rim of the ear, as shown inFig. 453.
This flap should be made slightly larger than the defect, since it contracts somewhat immediately after excision.
It is sutured rim down to the freshened wound in the wing.
The secondary deformity of the ear is brought together by suture. The author has found that this cannot be readily done without puckering the rim when the line of excision is made convexly, and advises making it triangular instead. The defect of the nose should be freshened to the same form. The flap from the ear now becomes ideal, fits better, is more readily sutured in place. No sutures should, however, be made through the apex of this triangular flap to avoid gangrene at this frail point. Silk isinglass at this point acts as a splint. Dry aristol dressings are used.
Fig. 453.—König Method.
Fig. 453.—König Method.
Fig. 453.—König Method.
Kolle Method.—When the defect of the ala is elongated and involves only part of the rim, the author has taken a cutaneo-cartilaginous flap from the back of the ear.
The flap is cut vertically, and is made to include a strip of cartilage of about the size and form of the defect.
The flap is immediately sutured to the freshened defect and folded upon itself with the cartilage facing the inferior margin of the defect.
The flap thus employed exhibits an epidermal face, both inside and outside as well as at the rim of the wing.
A case in which this method was used is shown in theillustrations 454 and 455, in which the defect is shown in the former figure, and the result after the sutures were withdrawn on the sixth day in the latter.
The secondary wound is easily brought together by suture, as the skin is quite flexible at this point.
Fig. 454.Fig. 455.Author’s Case.
Fig. 454.Fig. 455.Author’s Case.
Fig. 454.Fig. 455.
Author’s Case.
This defect of the nose has been restored by the use of skin flaps taken from the forehead, the nose itself, or from half or the whole thickness of the upper lip. The author does not advocate the use of such flaps except those taken from the skin of the inner side of the forearm, just below the wrist, made according to the Italian plan, as heretofore described.
The pedicle of such a flap is cut about the twelfth day, and at a later period, when the inferior or free margin has cicatrized, the subseptum is formed and sutured to the remaining stump or into a wound in the upper lip made to receive it.
The skin of the forearm is nearer to the thickness of the skin of the nose; hence a flap from it is preferable to that taken from the arm.
The method of obtaining the flap has been fully described heretofore.
The results obtained are excellent in most cases. The resulting cicatrix is barely visible, and may be later improved by scar-reducing methods, later described under that heading.
The appearance of the flap after the pedicle has been severed and the subseptal section has been put into place may be observed inFig. 456, and the final appearance after total contraction, inFig. 457.
Fig. 456.—Flap detached.Fig. 457.—Final appearance.Author’s Case.
Fig. 456.—Flap detached.Fig. 457.—Final appearance.Author’s Case.
Fig. 456.—Flap detached.
Fig. 457.—Final appearance.
Author’s Case.
For very small losses of tissue about the lobule nonpedunculated skin grafts are to be employed. The author advises including some of the areolar tissue with them to avoid contraction.
These are to be dressed with the blood method referred to under skin grafting. Perforated rubber tissue is to be used next to the epidermal surface to prevent the dressings from tearing away the graft when changed.
Fine twisted silk is most suitable for suturing purposes. The loops must not be drawn too tightly and the knot be made so that it rests upon the healthy skin of the nose.
For the correction of this defect various methods are given, and all of these must be modified more or less, to meet the requirements or extent of lost tissue. In some cases the entire subseptum is absent, while in others there is more or less of a stump remaining. Again in some, the subseptum required is unusually wide and in others quite narrow.
While a number of surgeons prefer making the flap to restore it from part or the whole thickness of the upper lip, as will be shown, the author believes the bestresults are to be obtained with the Italian flap method, if there be great loss of tissue, or to attempt to restore smaller defects with cartilage-supported nonpedunculated flaps taken from back of the ear, as heretofore described, or the cartilage to be used as a support may be taken from the nasal septum itself, having its pedicle posteriorly.
This strip of cartilage is brought downward, freed at either side from its mucosal attachment, and the skin flap to be used is then made wide enough to be sutured to the inferior mucosa margins as well as to the skin of the lobule.
The method of taking a sliding flap from the healthy skin of the nose is not advisable, because of the resultant disfigurement.
The tissue of the lip, on the other hand, can be used, since the secondary wound can be readily drawn together, leaving only a linear scar. In men, this may be hidden by the mustache.
When the Italian method is used, the method referred to in restoration of the lobule is to be followed.
Blandin Method.—The flap is taken vertically from the entire thickness of the upper lip, as shown inFig. 458, having its pedicle at the base of the nose.
This strip of tissue is turned upward, mucosa outward, and its freshened free end is sutured to the raw surface of the lobule.
The secondary wound of the lip is sutured as in ordinary harelip, as shown inFig. 459.
The mucosa soon takes on the appearance of skin, but in most cases remains pink in color.
The flap taken in this way should not be made too wide.
Fig. 458.Fig. 459.Blandin Method.
Fig. 458.Fig. 459.Blandin Method.
Fig. 458.Fig. 459.
Blandin Method.
Dupuytren Method.—The flap is taken vertically from the skin of the upper lip, reaching down at its free end to the vermilion border, as shown inFig. 460.
The flap is twisted upon its pedicle and sutured to the skin of the lobule; to facilitate this the left incision is made higher than that on the right.
The pedicle may be cut as with all such flaps, and it may be allowed to remain, if not too disfiguring.
The secondary wound of the upper lip is drawn together by suture, as shown inFig. 461.
The mucosa of the nose is to be sutured to the raw edge of the flap when that is possible.
Fig. 460.Fig. 461.Dupuytren Method.
Fig. 460.Fig. 461.Dupuytren Method.
Fig. 460.Fig. 461.
Dupuytren Method.
Serre Method.—This author advises dissecting up a flap from the upper lip, including the skin only, leaving it attached just above the vermilion border, as inFig. 462.
The free and upper end is sutured to the lobule. When union has taken place, the pedicle is divided and is brought upward and sutured into place. The secondary wound repaired by suturing finally. There is some difficulty in dressing the wound during the time required to have it unite to the skin of the lobule, because of the danger of pressure and consequent gangrene.
Fig. 462.—Serre Method.
Fig. 462.—Serre Method.
Fig. 462.—Serre Method.
Dieffenbach Method.—This author took up the skin flap transversely or obliquely, as shown inFig. 463, and twisted it into position, as shown inFig. 464.
The objection to the direction of making the flap in this manner is that the consequent cicatrization has a tendency to draw the mouth out of its normal position on the wounded side.
Fig. 463.Fig. 464.Dieffenbach Method.
Fig. 463.Fig. 464.Dieffenbach Method.
Fig. 463.Fig. 464.
Dieffenbach Method.
The following methods show the taking of the flapfrom the skin of the nose itself. Unless the defect be very small such methods are objectionable.
Fig. 465.—Heuter Method.Fig. 466.—Szymanowski Method.
Fig. 465.—Heuter Method.
Fig. 465.—Heuter Method.
Fig. 465.—Heuter Method.
Fig. 466.—Szymanowski Method.
Fig. 466.—Szymanowski Method.
Fig. 466.—Szymanowski Method.
Szymanowski Method.—In the latter method of Szymanowski the flap must be stretched considerably, to close over a lengthy deformity, encouraging gangrene. The deformity is not so great, however, as with the two preceding methods.