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 in
Fig. 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 folded upward 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.
[Illustration: FIG. 369.—KÖNIG METHOD.]
=Von Hacker Method.=—The frontal flap was cut in the ordinary Indian
method, and of the shape shown in Fig. 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.
[Illustration: 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 in Fig. 370.
The latter is done in an oblique direction. See Fig. 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 in Fig. 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 in Fig. 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 dissected up
sufficiently to permit of the proper formation of the sides and wings of
the nose.
This gives a shape to the nose, as shown in Fig. 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.
[Illustration: 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 in Fig. 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 in Fig. 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 subseptum is 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.”
[Illustration: 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 in Fig. 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 in Fig.
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.
[Illustration: 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. (See Fig. 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 in Fig. 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 to the marginal skin of the cheeks,
giving to the nose the appearance as shown in Fig. 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.
[Illustration: 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 in Fig. 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 in Fig. 383, this plate was made
from the frontal bone, being about two and a half centimeters wide and
four long.
[Illustration: 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. The bony plate is
sawed through at the median line, as shown in Fig. 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 in Fig. 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.
[Illustration: 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 in Fig. 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.
[Illustration: 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 (see Fig. 387).
[Illustration: 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 in Fig. 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.
CARTILAGINOUS SUPPORT OF FLAP
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 is the 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 excision requires
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 in Fig. 388.
[Illustration: 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 the right of the
nipple, as shown in Fig. 389, the length of the line being obvious.
[Illustration: 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 centimeter from the rib, after the costal
or inner extremity has been made.
The position of the hands and the exposed cartilage is shown in Fig. 390.
[Illustration: 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 in Fig. 391.
[Illustration: 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 in Fig.
392.
[Illustration: 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 (see Fig. 393).
[Illustration: 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.
PARTIAL RHINOPLASTY
RESTORATION OF BASE OF NOSE
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
in Fig. 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 in Fig. 395.
The method is purely of the Hindu type, and the results are not,
therefore, very satisfactory.
[Illustration: 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 the lateral parts brought down by
the former incisions, to which it is sutured at the median line, as shown
in Fig. 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 flaps
_A_, _B_, _C_, are turned down from the point _A_, which represents the
pedicle, and are sutured at the median line by their lower borders, _A_,
_B_, the borders _B_, _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 in Fig. 397.
This procedure will leave two exposed areas at either side of the nose,
which are permitted to heal by granulation.
[Illustration: 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 in Fig. 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 in Fig. 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 in Fig.
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.
[Illustration: 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 in Fig. 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 surface looking 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 in Fig. 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.
[Illustration: 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 in Fig. 403.
[Illustration: 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 in Fig. 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 in Fig. 405, in which the lateral nasal surface is left
uncovered to show the space occasioned by the removal of the nasal bone,
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.
[Illustration: 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 in
Fig. 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, being attached 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 in Fig. 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.
[Illustration: 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 in Fig. 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 bony plate 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 in Fig. 409.
[Illustration: 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 in
Fig. 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 in Fig. 411.
[Illustration: 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 support taken from the eighth costal
cartilage, as previously described, would undoubtedly give the best
results.
RESTORATION OF LOBULE AND ALÆ
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 in Fig. 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 in Fig. 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 in Fig. 414.
[Illustration: 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 in Fig. 415.
The adherent Italian flap and its subseptal addition and the outlines for
the lining flaps are shown in Fig. 416.
The secondary nasogenian wounds reduced by suture and the flaps so
obtained are shown in Fig. 417. The subseptal section of the Italian
flap is raised to show 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.
[Illustration: 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.
RESTORATION OF THE ALÆ
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 linear scars
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.
[Illustration: 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.
[Illustration: 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.
[Illustration: FIG. 424. FIG. 425.
VON LANGENBECK METHOD.]
=Busch Method.=—The same method as above is employed except that for the
incision _A_, _C_, which, upon dissection of the skin in triangle _A_,
_B_, _C_, allows the closure of a larger defect than could be corrected
with the lateral nasal flap alone (see Fig. 426).
[Illustration: 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.
[Illustration: FIG. 427.—DIEFFENBACH METHOD.]
[Illustration: FIG. 428.—DUPUYTREN METHOD.]
[Illustration: FIG. 429.—FRITZ-REICH METHOD.]
[Illustration: FIG. 430. FIG. 431. FIG. 432. FIG. 433.
SEDILLOT METHOD.]
[Illustration: 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.
[Illustration: FIG. 436. FIG. 437.
BONNET METHOD.]
=Weber Method.=—The flap is made from half the thickness of the upper
lip, as shown in Fig. 438, and brought into the defect, as in Fig. 439.
The pedicle is cut later.
[Illustration: FIG. 438. FIG. 439.
WEBER METHOD.]
=Thompson Method.=—This author uses a lateral flap taken from the cheek,
as shown in Fig. 441, and lines it with a flap of mucosa dissected from
the septum antero-posteriorly, as shown in Fig. 440, disposing of the
latter flap as shown. The raw surface meets the raw surface of the skin
flap, as in Fig. 442.
At a later sitting the two pedicles must be severed and adjusted by small
minor operations.
[Illustration: FIG. 440.—Mucosa flap.
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.
[Illustration: 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 in Figs. 445 and 446.
[Illustration: FIG. 445. FIG. 446.
VON HACKER METHOD.]
=Kolle Method.=—The author dissects away the flap _E_, _A_, _D_ when
part of the mucosa and cartilaginous tissue remains, and where there is
a loss, total or partial, of the alar rima, the transverse incision _E_
being made as long as required to overcome the defect by sliding, as in
Fig. 447.
The latter flap is freshened at its inferior border along the line _D_,
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 area _C_.
The lateral or upper flap is now slid down to slightly overcome the loss
of tissue and the flap _C_ is brought upward by twisting slightly on its
pedicle and sutured in place, as shown in Fig. 448.
The secondary wound lying between the lines _E_ and _E’_, occasioned by
the sliding downward and leaving the triangular defect _F_, is allowed to
heal by granulation. The lateral flap is fixed along the line _A_.
Usually the pedicle of flap _C_ need 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.
[Illustration: 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 in Fig. 449.
The flap _A_, _B_, _C_ includes the skin and such cartilage as can be
used, while the rim below the line _B_, _D_ retains 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 line _B_, _D_ the whole thickness of
the tissue except the overlying skin is involved.
[Illustration: FIG. 449.—DENONVILLIER METHOD.]
=Von Hacker Method.=—The flap _A_, _F_, _C_, as shown in Fig. 450, is
cut from the entire thickness of the side of the nose attached by its
posterior pedicle _C_.
This flap is moved downward, and its anterior border is sutured along the
freshened line _A_, _B_, as in Fig. 451, leaving a triangular defect,
_A_, _F_, _C_.
Two little triangular flaps of skin are dissected up, skin only, at _D_,
_E_, _C_ and _H_, _G_, _C_.
Next a rectangular flap, _I_, _K_, _L_, _M_, is dissected up from the
cheek, as in Fig. 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.
[Illustration: 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 the entire thickness of the rim of the ear,
as shown in Fig. 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.
[Illustration: 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 the illustrations 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.
[Illustration: FIG. 454. FIG. 455.
AUTHOR’S CASE.]
RESTORATION OF NASAL LOBULE
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 in Fig. 456,
and the final appearance after total contraction, in Fig. 457.
[Illustration: 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.
RESTORATION OF SUBSEPTUM
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 best results 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 in Fig. 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 in Fig. 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.
[Illustration: 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 in Fig. 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 in Fig. 461.
The mucosa of the nose is to be sutured to the raw edge of the flap when
that is possible.
[Illustration: 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 in Fig. 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.
[Illustration: FIG. 462.—SERRE METHOD.]
=Dieffenbach Method.=—This author took up the skin flap transversely or
obliquely, as shown in Fig. 463, and twisted it into position, as shown
in Fig. 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.
[Illustration: FIG. 463. FIG. 464.
DIEFFENBACH METHOD.]
The following methods show the taking of the flap from the skin of
the nose itself. Unless the defect be very small such methods are
objectionable.
[Illustration: FIG. 465.—HEUTER METHOD.]
[Illustration: 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.
[Illustration: FIG. 467. FIG. 468.
SZYMANOWSKI METHOD.]
The author believes a nonpedunculated flap with or without a
cartilaginous support should be tried before other methods are resorted
to, in all cases, with the hope of healing the graft in place. The fact
that the mucosa can in some cases be sutured to the margins of the
flap adds much to the possibility of its subsequent life by adding its
nutriment to the graft.