INDIAN METHOD.—In this procedure a pear-shaped flap, somewhat larger than needed to make up the aggregate of soft tissues that would represent a normal nose, is mapped out on the forehead. The flap should lean somewhat toward one of the eyebrows, the narrow portion corresponding to the root of the nose and forming a pedicle one-half inch wide. This being done, the edges of the nasal opening are carefully freshened and leveled, a regular bed being pre pared for the flap which is to cover it. The pear-shaped flap is then carefully detached with the periosteum from the frontal bone, twisted down around its pediele, adjusted to the freshened tis sues around the nasal orifice, and so ad justed as to cause a bend in the flap to correspond with what would represent a nasal bridge. Two hard-rubber tubes shaped like the anterior nares should be inserted under the flap so as to preserve patcncy, and the flap sutured in place. The objection to this operation is that it leaves a scar.
Schimmelbusch, recognizing that only partial cosmetic and functional results are secured in the operation, for the reason that for want of support the new nose gradually sinks and then more and more shrinks, resorts to the following operation: A three-cornered skin-and bone flap is taken from the middle of the forehead. This flap is so cut out with the knife that the smaller base is at the root of the nose, and the broader side lies exactly in the middle of the forehead. With a sharp, broad chisel the anterior surface of the frontal bone represented by the flap is chiseled off. From the angles of the forehead-defect, large, arched incisions are carried over the skull toward the ears, and the flaps loosened and sutured over the forehead. In this manner simple linear scars re main in the forehead. The loosened flap must first be allowed to granulate, and then it is transplanted upon the wound-surface. The bone-plate is sawed along its middle line and folded together in the form of the nose. This formed flap is then sutured into the freshened wound in such a way that the raw sur face stands posteriorly and the face anteriorly. The septum of the nose is simply obtained from the skin in the deformed nose; so that strips of skin are taken from the sides of the defect as far as the natural position of the septum.
The tip of the nose is also formed from the original nose. The first week a sil ver wire with buttons on either end is passed through the nose at the level of the alm, and left in place until the sepa ration of the forehead flap and the end of the operation. This helps form the configuration of the alw by its lateral pressure.
The Italian method consists in utilizing a flap taken from the arm of the patient, over the biceps, at a spot corresponding with the nose when the hand is applied over the head from the front. The flap is so shaped as to assume that of the nose when in, situ, an allowance of one-third being allowed all around it for shrink age. It is detached from the arm only partly, however, a pedicle being pre served to insure nutrition of the sepa rated tissues. The flap is left in this condition about two weeks, in order to enable it to become vascular and covered with granulations underneath. At the end of this time the nasal orifice is pre pared as for the Indian method; the forearm is placed over the head and fastened there by bandages, and the flap is adjusted to the pared nasal edges and sutured. The patient must remain in this trying position about twelve days, when, the flap having become adherent, the pedicle may be cut and the arm re leased. The pedicle is then trimmed off to give it a shapely appearance, and a column is either formed with it or with a small flap taken from the upper lip. The procedure is often successful, but its irksomeness, and the fact that a presentable nose is seldom obtained, cause it to be seldom employed.
In the less marked deformities of the nose, which usually affect the dim, a small flap may usually be obtained from the cheek, or from the forehead if a large one is necessary. A pedicle should always be left to insure nutrition of the flap while it is becoming adherent to the tissues over which it is applied. If the redundant portion due to the pedicle is in any way unsightly, it may be sur gically adjusted as soon as the nasal flap is thoroughly nourished through its new channels. (See SKIN-GRAFTING, vol. vi.)