PARTIAL RHINOPLASTY

Fig. 369.—König Method.

Von Hacker Method.—The frontal flap was cut in the ordinary Indian method, and of the shape shown inFig. 355. The skin at either side of the median line was dissected up to within four millimeters, leaving a strip eight millimeters wide from the root of the nose to the distal or scalp end. The two loose lips of the flap were brought together at the anterior median line by a few sutures to keep them in place.

This was done to give freedom to the surgeon while he detached a strip made of the periosteum and bone chiseled from the frontal bone. At the root of the nose or below the pedicle the bone was not included to the extent that it would interfere with torsion of the flap, and yet sufficient to allow the raw bone surface to fall upon what remained of the bony bridge of the old nose.

Fig. 370.—Arrangement of frontal flap to allow of chiseling.Fig. 371.—Making the osteoperiostitic support.Fig. 372.—Bone-lined flap brought into position.Von Hacker Method.

Fig. 370.—Arrangement of frontal flap to allow of chiseling.

Fig. 371.—Making the osteoperiostitic support.

Fig. 372.—Bone-lined flap brought into position.

Von Hacker Method.

He utilizes pins driven into the bone to outline this bony section, as shown inFig. 370.

The latter is done in an oblique direction. SeeFig. 371. The septal section is made to include the bone strip.

The bridge of bone holding the flap at its inferior end was now broken, leaving, however, the periosteum as part of the pedicle hinge.

The whole flap thus outlined was rotated downward into position and sutured, as shown inFig. 372.

The margins at the base intended to form the subseptum were sutured behind the osseous structure, or, in other words, were doubled inward and fixed by suture. The bony strip was broken at the proper point to give prominence to the lobule.

The margins for the nostrils were turned inward and doubled on themselves, and sutured with silk.

Rubber tubes were left in the nares, for drainage and to keep them distended.

Rotter Method.—The frontal flap is made in the shape shown inFig. 373, containing a section of the frontal bone and its periosteum. The width of the flap is about three and a half centimeters wide.

This flap is turned downward so that its raw surfaces look outward.

Owing to the loose adherence of the bony section to the skin flap, he allows the raw bone surface to granulate over for four weeks, to fix it more solidly to the soft parts.

The bone plate is then sawn into three sections made by two vertical incisions, made as shown in the illustration.

The median section forms the bridge and dorsal prominence of the nose.

The adherent skin of the lateral bony plates is dissectedup sufficiently to permit of the proper formation of the sides and wings of the nose.

This gives a shape to the nose, as shown inFig. 374.

The lateral margins of the integumentary flap are now sutured to the freshened margins of the old nose, and the remaining skin, if any, is made to cover the granulating surface; if this is lacking or insufficient, skin grafts are utilized to cover it completely.

Fig. 373.—First step.Fig. 374.—Disposition of frontal flap.Rotter Method.

Fig. 373.—First step.

Fig. 374.—Disposition of frontal flap.

Rotter Method.

Schimmelbusch Method.—The principle herein is to give an osseous wall to the whole length of the restored nose, covering well the skin inside and outside, and, if possible, to fix the new nose solidly at the pyriform opening.

“I cut an osteo-cutaneous flap from the middle of the forehead, of a size proportional to the size and shape of the nose. Its pedicle between the eyebrows is two or three centimeters wide; it widens out superiorly to form seven to nine centimeters. It is triangular, and its base lies near the hair line. In cutting it out, preferably a little large, it goes at first to the bone, through skin and periosteum. With a large, sharp chisel, a thin bone plate throughout the whole extent of the cutaneous flap is detached.It is not always possible to make this a plate in one piece; it often breaks or gives off splinters. This is of no consequence, if care be taken not to lose them and to keep them adherent to the periosteum. They are attached as well as possible to the cutaneoperiostitic flap by passing threads crosswise from one edge of the flap to the other over bony surface, as inFig. 375. The whole flap is then enveloped in iodoformed suture.

“The frontal wound I close at the same sitting by sliding large lateral flaps whose upper border follows the margin of the hair as far as the ears. These are freed completely, brought down and stitched, leaving eventually only a linear cicatrix on the forehead. The lateral loss of substance which results is healed by granulation, and the scars concealed by the hair.

“At first parts of the bone die; they ought to be expected to fall out; after four, six, or eight weeks the bone is completely covered with fleshy granulation, and adheres solidly to the flap. The prominent granulations are then scratched, or, better, trimmed away with the knife, and the whole surface is covered with Thiersch grafts.

“When the flap is thus furnished with skin within and without, it is put into place. I saw the bony plate with a fine-toothed saw from the grafted side; then I model the flap and place it on the loss of substance freshened by turning the grafted surface toward the interior of the nose by twisting its pedicle, as inFig. 376. The osseous rim of the pyriform opening is uncovered at the moment of this freshening, and the bony edges of the flap are placed exactly on the bony edge of the aperture. The skin of the flap is then stitched at its lower margins to the skin of the cheeks. To preserve the height of the nasal profile and avoid displacing the bones of the nose, the nose is kept in place with a pin thrust through the nose, and furnished at each end with a rubber button. This aids to form the wings of the nose. If a subseptumis needed, it is made by taking from the skin that covers the circumference of the pyriform opening two small flaps, which are dissected from without toward the median line as far as the point where the septum is normally found.

“These are stitched at this point, first upon themselves, then to the end of the nose. Three weeks later the pedicle of the frontal flap is cut; it is turned, put in splints, and the stitching is finished.”

Fig. 375.—First step.Fig. 376.—Disposition of frontal and skin-grafted flap.Schimmelbusch Method.

Fig. 375.—First step.

Fig. 376.—Disposition of frontal and skin-grafted flap.

Schimmelbusch Method.

Helferich Method.—A lining flap is made, according to the French method, from the one cheek, which is dissected up and turned over to bridge most of the loss of nasal tissue, and sutured to the opposite freshened margin, as showed inFig. 377.

A frontal flap, as outlined in the same illustration, is now cut from the forehead, leaving a pedicle as shown, and containing a section of bone at its median line. This is rotated downward and into place, and sutured along the same margin to which the genian flap is fixed, as shown inFig. 378.

When the frontal and genian flaps have become well united, the latter’s pedicle is cut when the freshened lateral margin of the frontal flap is sutured into place.

A subseptum is now made or deemed necessary by this surgeon.

At a later period the pedicle of the frontal flap is cut, and fixed by suture and some cutting, to reduce the resultant prominence thereof.

Fig. 377.Fig. 378.Helferich Method.

Fig. 377.Fig. 378.

Helferich Method.

Preidesberger Method.—This author cuts away the skin surrounding the arch of the old nose, and turns this flap downward to form the lining to the flap made from the forehead made in the same manner as Helferich.

The bone section is made in the median line, and is one centimeter wide and four long.

The frontal flap should be made long enough to permit of building a subseptum and the nostrils.

Krause Method.—This frontal cutaneo-osteo-periostitic flap is made according to the method of König.

After turning down the flap it was covered with a nonpedunculated skin flap taken from the upper part of the arm by transplanting after its subcutaneous fatty tissue had been removed. (SeeFig. 379.)

This method necessitates a long-continued dressing of the forehead before the pedicle is cut, because of the needed nutrition to make the two flaps heal upon each other.

After union has been established the sides of the transplanted flaps are raised by dissection, as shown inFig. 380, to expose the bone plate of the frontal flap. A median strip is left intact.

With a fine saw the bony plate is cut into three sections, making the narrowest the median.

The margins of the old nose are now freshened, and the combined flap is sutured along the sides, preserving what tissue the surgeon can use to add support to the nose, which is done by dissection and turning or folding, as heretofore described.

The lower or forehead flap is sutured to the soft parts of the old nose, and the transplanted lateral margins tothe marginal skin of the cheeks, giving to the nose the appearance as shown inFig. 381.

At a later period the pedicle is cut and the wound that cannot, at this time, be overcome by sliding of the adjacent skin, is covered by skin grafting.

Fig. 379.—First step.Fig. 380.—Second step.Fig. 381.—Third step.Krause Method.

Fig. 379.—First step.

Fig. 380.—Second step.

Fig. 381.—Third step.

Krause Method.

Nélaton Method.—A lateral flap of skin is taken from the cheeks, beginning on a line with the root of the nose and as low as a point two thirds of its normal length. These flaps are made wide enough, so that when dissected up and folded inward they will meet on the median line, as shown inFig. 382, having their raw surface facing outward. They are sutured along the median line. The frontal flap was cut in the form of a horse-shoe having its pedicle at the root of the nose just above the eyebrows, and being about three centimeters wide and six long.

The skin at the outer margins was dissected up from the bone, leaving sufficient attachment at its center to allow for a bony plate.

With a fine saw, and in the manner shown inFig. 383, this plate was made from the frontal bone, being about two and a half centimeters wide and four long.

Fig. 382.—First step.Fig. 383.—Making bony support to flap.Nélaton Method.

Fig. 382.—First step.

Fig. 383.—Making bony support to flap.

Nélaton Method.

There is some difficulty associated with the making of the flap, which ends at the superior border of the frontal, leaving the pedicle composed only of skin.

The flap is now turned down, exposing its raw surface. Thebony plate is sawed through at the median line, as shown inFig. 384, and the skin of the flap is also divided along this line, giving two partly bone-lined flaps.

The two flaps are now rotated downward before the lost nose, so that their raw surfaces face inward, and in this position they are sutured along the median line and the sides, as shown inFig. 385.

The method gives an angular dorsum of satisfactory consistency to the new nose, but furnishes a serious drawback, in that the cicatrization along the median line is liable to affect the shape of the organ and leaves a prominent scar line. The use of two small pedicles is another objection in that the danger of gangrene is greater as the nourishment to each flap is less.

Fig. 384.—Cutting through bony plate.Fig. 385.—Disposition of frontal flap.Nélaton Method.

Fig. 384.—Cutting through bony plate.

Fig. 385.—Disposition of frontal flap.

Nélaton Method.

Israel Method.—From the ulnar side of the left forearm Israel cuts a skin flap, as shown inFig. 386, with its smaller end nearest to the wrist, where it is detached, the pedicle being broad, assuring of better nourishment to the flap.

The narrow end of the flap is cut down to the bone, then the sides are dissected up until the borders of the ulna are reached on both sides, reserving an adherent strip about eight millimeters wide and six centimeters long.

Fig. 386.—Israel Method.

The bone below this strip is now removed with the saw from the lower end upward, and ending about one centimeter beyond the base line of the flap, where the strip so made is left connected to the bone proper.

The flap is now raised gently and bent upward without breaking the bone. It is sawed half through, transversely, at a point corresponding to the lobule of the nose.

The flap is then enveloped in iodoform gauze, and the head, forearm, and arm are fixed in plaster of Paris, the forearm being bent at a right angle to the arm (seeFig. 387).

Fig. 387.—Israel Method.Position of forearm for placing of flap.

After nine days the osseous connection still remaining is severed, and the nose is modeled upon the forearm, as heretofore described in these operations, this surgeon using silver wire to retain the parts. The raw skin surfaces are allowed to heal upon each other and the flap is permitted to come in contact with the wound on the forearm temporarily, to which it might adhere, the gauze being now removed.

After twelve days the newly modeled nose is freed from such adhesions and kept from healing to the parts by using dressings between the flap and wound.

Five days after, the margins of the old nose are freshened in the form of an inverted V. If there be sufficient cicatricial tissue it is turned down, raw surface out, to line the new nose.

A prolongation of the pedicle is now cut, widening out toward the radial side of the arm, made obliquely, as shown, so that its pedicle now corresponds to a width of seven centimeters.

The whole flap except this newly formed pedicle is cut free of this forearm. The arm is put into the position shown inFig. 387, and the freshened flap margins at the root, the whole length of the left side, and part of the upper right lateral. The plaster dressing to hold the arm in the proper position until complete union is established is used. This done, the pedicle is cut, and such minor operations are done to fix the remaining free margin and the base of the new nose.

The methods just described in which an osseous plate of various size and form is included with skin flaps for the restoration of the nose give undoubtedly the best rhinoplastic results. The new nose is given not only better shape, but a permanency of such form that skin flaps of themselves could never give.

The unfortunate factors in these osteo-cutaneous operations are the many difficulties experienced.

The cutting or making of the bony plate is no simple task.

The skin is an uncertain agent to employ, because of the peculiar contour of the bony surface from which the plate is to be removed. The chisel, no matter how dexterously used, is liable to cut through the entire bone thickness, which has occurred in several recorded cases.

There is also the possibility of necrosis of a part or all of the bony plate thus obtained, and where the latter is not lined interiorly there is the added danger of infection.

Furthermore, the secondary wound is more extensive; the bone exposed requires about a month’s time to granulate over before skin grafts can be successfully applied over it.

With the employment of a cheek-flap lining there isthe added objection of cicatrization. The use of a flap from the arm is complicated and requires considerable time for the completion of the operation, and there is always the added danger of infection and consequent death of the osseous plate.

To overcome these many difficulties von Mangold advocates the use of a section of cartilage to support the anterior prominence of the nose.

It has been found, since the first attempt of and the successful result obtained in 1897 by this surgeon, that cartilage to be used for this purpose should be taken from the costal cartilage, where a strip of the required length and width can be obtained.

The results thus far recorded are excellent, and much is hoped for from this method, especially in the reconstruction of loss about the wing of the nose in partial rhinoplasties, where the convexed contour may be reproduced to a nicety.

The first attempt to support the flap for a total rhinoplasty by this method was made in 1902 by Charles Nélaton.

The use of cartilaginous supports may be combined with any of the methods given heretofore. The flap containing the cartilage may be lined or unlined. All tissue found about the old nose should, of course, be utilized to give added support and to reduce as far as possible extensive secondary cicatrization.

The combined Hindu and Italian methods give splendid results, the frontal flap and its support being brought down from the forehead, raw surface outward, and the arm or forearm flap being placed immediately in front of it.

The frontal flap with the support requires a preliminary operation to permit of the attachment of the cartilage. Fortunately, this step requires but little time and shows a very slight disfigurement during this period.

The secondary wound at the site of the cartilage excisionrequires little attention and heals readily, and the cicatrix involved is very small.

Steinthal proposes taking the flap and cartilage from the thoracic region, grafting it during the preparatory period to the forearm, from which it is transplanted to the face at a second sitting.

There is the objection to this method that it requires the arm to be retained in position for a very long time.

The author advocated the use of an arm flap made by the Italian method to line the one to be brought down from the forehead in cases of total rhinoplasty where little or no tissue can be obtained from the remains of the old nose. Such procedure reduces the time required by the Steinthal method to one half, and therefore greatly lessens the discomfort to the patient.

The fundamental principles as laid down by Nélaton are excellent, and may be applied to any modification of method the surgeon may decide upon where a section of costal cartilage is employed to support the flap, whether this be taken from the forehead, other parts of the face, or remote places.

The procedure of Nélaton is as follows:

Nélaton Method.—The method involved a preparatory and a final operation.

The preparatory operation has to do with obtaining and placing in position the section of cartilage under the skin flap wherever located.

The final operation may or may not consist of two sittings, the first being necessitated by the bringing upon the remains of the nose a flap of skin to line the one brought down in front of it and containing the support.

Preparatory Operation.—To begin properly, the frontal flap to be utilized is marked out on the forehead with nitrate of silver the day before the operation, so that its outline will be plainly discernible, and act as a guide for the placing of the cartilage. The shape of the flap is fashioned as shown inFig. 388.

Fig. 388.—Nélaton Method.Outlining of frontal flap.

In the illustration is also shown the incisions later made to utilize the borders of the remaining nose to line the frontal flap. This is done by making an inverted V incision at a distance from the inner borders, corresponding to the lateral line of union of the frontal flap with the face. The resultant flap is turned down, raw surface outward, curtainlike, and is sutured to the frontal flap, where it falls into position.

The flap outline shows that its pedicle lies between the outer end of the inner third and above the right eyebrow and a little to the left of the median line at the root of the old nose. This will avoid considerable tension at this point, the rotation as made being ninety degrees.

Nearly horizontally, as shown in the figure, a line is drawn through the center of the flap, showing the position the strip of cartilage is to occupy.

This done, a pattern of the outline is cut from stiff paper or oiled silk to preserve as a guide for the making of the flap, it being understood that the outlining has been made to the measurement of the required nose, allowance being given for cicatricial contraction.

This done, the surgeon having prepared the skin about the costal prominences of the left thorax, he proceeds as follows:

A vertical line is drawn the width of two fingers to theright of the nipple, as shown inFig. 389, the length of the line being obvious.

Fig. 389.—Method of Locating Strip of Cartilage.

Where the vertical crosses the eighth costal cartilage an incision is made downward over and not under the border of the cartilage.

The incision extends downward for a distance of eight centimeters, where it is turned upward at an angle, as shown, to a distance of three centimeters.

By separating the muscular aponeurosis made visible by this incision the lower edge of the eighth costal cartilage is exposed. The knife is moved along the lower edge of the cartilage, dividing the fibers of the insertion of the transverse muscle from without inward. The cartilage can now be grasped between the thumb and forefinger and be forced out of its normal position after a slight anterior dissection.

The union between cartilage and bone is exposed. The chisel is used to divide the cartilage about one centimeterfrom the rib, after the costal or inner extremity has been made.

The position of the hands and the exposed cartilage is shown inFig. 390.

Fig. 390.—Excising Strip of Costal Cartilage.

This accomplished, the wound is temporarily dressed. The cartilage is then fashioned to suit the required size and shape.

It is thinned down on its lower surface to about three millimeters in diameter. This thickness is maintained to a length of two and a half centimeters, the part being intended for the subseptum.

A notch is made on the upper surface at this distance from the end, which marks the point at which it must be eventually bent to form the point of the nose. This notch is cut to two thirds of the entire thickness.

The required length, that of the nasal line and its added septal length, is preserved.

The cartilage being prepared is now ready for the insertion under the frontal periosteum at the site already marked.

For this purpose a vertical incision one and a half centimeters, extending down to the bone, is made, as shown inFig. 391.

Fig. 391.—Cartilage Placed under Frontal Flap.

The periosteum is peeled away from the bone with the dull or rounded handle of a knife.

The cartilage is now thrust into the tunnel thus made, the thinned-down, notched-off section facing forward and lying toward the vertical incision.

The skin wound is sutured and a gentle compress is used to keep the cartilage in contact with the periosteum, which requires at least two months. A longer interval of time is advocated to give greater vitality to the cartilage.

The wound of the thorax is simply sutured and dressed as any surgical wound.

Final Operation.—The part cut is prepared as in the Hindu method. A lining for the frontal is made of such tissue as remains, and its freshened borders are sutured where possible, as shown in the last figure.

When this cannot be done, a flap may be taken from the arm, as already suggested, or a Krause nonpedunculated skin flap may be used, according to the methods given heretofore.

The epidermis is made to face inward. If either of these methods is used, the frontal lap is not brought down until healthy granulation has been established.

The frontal flap is made to include the periosteum, from which it is separated with a blunt instrument. The cartilaginous strip will be found to be attached to the periosteum.

The freed flap is now brought before the nasal defect and fitted into place. The cartilaginous strip should occupy the anterior median line.

The subseptal cartilage is bent inward and downward and the skin of the flap is sutured to it with catgut to form the subseptum, as shown inFig. 392.

Fig. 392.—Bringing Down Frontal Flap.

The free margins of skin remaining at the septal bone of the flap are folded inward to line the new nostrils. Catgut sutures are used to keep these folds in position.

The nose is now ready to be sutured into place. The subseptum is inserted first and fixed into the upper lip, then the nose being held so that its median line occupies the proper position, both wings are sutured to the freshened margins, and lastly the sides (seeFig. 393).

Fig. 393.—Placing of Frontal Flap.

The frontal wound may be drawn together as near as possible by suture.

Rubber drainage-tubes are kept in the nares for a few days, and are thereafter replaced by rolls of gauze.

Dry dressings are preferred for the nasal wounds, which heal in about five days.

A month after, Thiersch grafts are employed to cover the frontal wound remaining. They require about eight days to heal into place.

In this defect there may be a loss of the lobule and both alæ, including the subseptum, or there may be a lateral loss, involving more or less of the base.

There are many types of this deformity, so that to include all would involve considerable space, and at best most of the operations involved would be those utilizing the methods heretofore mentioned.

The earlier operations for the correction of lesions of large extent are founded upon the use of skin flaps, which have been shown to be unsatisfactory because of their consequent cicatrization. Reference is made, however, to several of these to exhibit the disposition of the remaining parts of the old nose.

Later will be considered the methods involving osteo-cartilaginous supports.

Steinhausen Method.—The inferior remains of the old nose are detached from the margins and brought downward; a Hindu flap is fashioned as shown inFig. 394, and brought down to form the new nose; the size of the flap is given as being four inches wide and eight inches long.

The distal end of the flap is sutured to the freed flaps obtained from the borders, as shown inFig. 395.

The method is purely of the Hindu type, and the results are not, therefore, very satisfactory.

Fig. 394.Fig. 395.Steinhausen Method.

Fig. 394.Fig. 395.

Steinhausen Method.

Neumann Method.—This author cuts down the remains of both lower margins of the old nose, as in the Steinhausen operation. A wedge-shaped section is cut from the entire thickness of the upper lid and turned upward to form the subseptum, and is sutured to thelateral parts brought down by the former incisions, to which it is sutured at the median line, as shown inFig. 396.

Two lateral flaps are now made from the sides of the remaining nose retaining their cartilages, as shown in the illustration,A,B,C,D, showing one of them. The two flaps remain attached, anteriorly along the median line over the bridge of the nose. These two lateral flapsA,B,C, are turned down from the pointA, which represents the pedicle, and are sutured at the median line by their lower borders,A,B, the bordersB,C, being thus brought down, fall before the fresh borders taken from the margins of the old nose, to which they are sutured, as shown inFig. 397.

This procedure will leave two exposed areas at either side of the nose, which are permitted to heal by granulation.

Fig. 396.Fig. 397.Neumann Method.

Fig. 396.Fig. 397.

Neumann Method.

Later Neumann Method.—An incision is made to circumscribe the remains of the old nose at either side, extending upward in rectangular form above the root of the nose, between the inner canthi and upward, and somewhat above the eyebrows, as shown inFig. 398.

This flap thus outlined is freely dissected down to the bones of the nose, leaving it attached only at the roots of the wings, so that it can be turned downward, hanging over the mouth, like a curtain.

A deep transverse incision is then made through the remaining cartilaginous structure of the nose, just below the inferior borders of the nasal bones. This gives a cartilaginous, archlike support to this part of the flap, which is utilized to give firmness and shape to the base of the new nose.

The incision just mentioned is depicted inFig. 399, in which is also shown the turned-down flap.

After the hemorrhage has been controlled the flap is turned upward and into such position as to form the new nose, utilizing the cartilaginous arch, above referred to,to the best advantage to give the proper contour. This will lower the apex of the flap considerably. The lateral borders are sutured to the freshened margins where possible, but as a rule an opening is left at either side, communicating with the inner nose, which must be healed by granulation.

The wound on the forehead may be brought together completely by suture. The appearance of the nose assumes at this time the form shown inFig. 400.

The objection to this method lies in the fact that the cartilaginous arch brought down with the flap is usually insufficient to give proper support to the base of the nose, permitting the lobule to contract and sink. In most cases there is an absence of sufficient cartilage to employ the method at all. An osseous arch would, therefore, preferably be incorporated with the flap, taken from the remaining nasal bones.

Fig. 398.Fig. 399.Fig. 400.Later Neumann Method.

Fig. 398.Fig. 399.Fig. 400.

Later Neumann Method.

Bardenheuer Method.—This author makes a transverse incision across the root of the nose, and two lateral incisions from either end of the first, carrying them downward and outward, as shown inFig. 401. These incisions are made down to the bone. With a chisel the nasal bones are separated from their frontal and superior maxillary attachments, giving an arch of bone to the flap, which is brought downward and outward, the bone being dissected from the underlying mucosa. To facilitate the bringing down of this flap the anterior border of the cartilaginous septum must be divided if present.

The flap thus made is attached only at the two points of skin at the inferior borders, the epidermal surfacelooking inward. The archlike mass of bone is gently bent backward at either side to practically reverse its convexity. The position of the flap is shown inFig. 402.

The raw surface of the flap above mentioned is now covered with a flap taken from the forehead in the form shown in the figures.

The resultant nose is entirely lined with skin, and contains sufficient bone to support it. The objection is that there must necessarily be a large secondary wound in the forehead, which must be covered with Thiersch grafts.

Fig. 401.—Shape of flap.Fig. 402.—Disposition of nasal flap.Bardenheuer Method.

Fig. 401.—Shape of flap.

Fig. 402.—Disposition of nasal flap.

Bardenheuer Method.

Ollier Method.—This author uses an inverted V incision, beginning on the forehead at a point about three centimeters above the superior margin of the eyebrows. The diverging incisions are carried down to a point just above the base of what remains of the old nose, where it remains attached.

The shape of the flap thus made is shown inFig. 403.

Fig. 403.—Ollier Method.First Step.

The flap is dissected up and made to contain the periosteum as far as the juncture of the frontal nasal bones.

The skin over the right nasal bone is now dissected up, without, however, including the periosteum. The left nasal bone, still adherent to the skin, is removed with the chisel, beginning at the median line, then at its frontal attachment, and lastly along its union with the superior maxillary bone.

On the right side what remained of the cartilaginous structure was divided so as to include it in the flap.

This gave a large triangular flap, periosteo-cutaneous above, osteo-cutaneous below that, and ending in a chondro-cutaneous border, attached to the face by a double pedicle, as shown inFig. 404.

To give further support to this flap at the median line, Ollier divided the septum with the scissors in such a way as to form an antero-posterior cartilaginous flap attached by its lower base.

The flap was brought downward in the same manner as in the method of Neumann and sutured into position, the parts involved assuming the position shown inFig. 405, in which the lateral nasal surface is left uncovered to show the space occasioned by the removal of the nasalbone, and in dotted line the position that bone now occupies.

In five weeks the two nasal bones united, end to end, and three months after the operation the space made by the removal of the bone had become filled with hard tissue, that eventually ossified in about seven months.

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