III. When the flap had become dry he fitted the linen bandage apparatus to retain the arm. Then the borders of the old nose were freshened. Thereafter he cut a paper pattern as a model for the new nose, upon which the margins and shape of the flap were cut. The flap was finally sutured in place, and the apparatus was tightened to prevent movement of the parts.
IV. After twenty days he cut the pedicle. The latter was then cut into, to divide it in three parts, which he formed into the subseptum and nasal wings, which were sutured in place, metal tubes being employed to keep the nares open.
Dieffenbach Method.—This surgeon followed seven steps to complete the operation, as follows:
I. The pattern of the new nose, cut one third larger, is fixed upon the skin of the arm, with the basic pedicle just above the fold of the elbow. Skin is now raised sufficiently to permit of its being incised, the incisions being made laterally, as shown in the dark lines in [Fig. 347].
This gives a triangular flap, the apex lying upon the biceps and having two adherent pedicles at apex and base.
The base is now incised at one angle, transversely and again vertically, as shown. This incision liberates the part of the flap intended for one of the ala of the nose.
II. Diachylon plasters are placed under the flap to contract the arm wound immediately the bleeding has been arrested. The free angle of the base of the flap is now turned inward and under the attached part of the flap, as in [Fig. 348], so that its margin protrudes from the other lateral incision, and its skin surface lying above the plaster. The edges of the flap are now stitched together, and the flap is allowed to lie cushionlike upon itself while the arm wound heals. This requires about six weeks.
Fig. 347. Fig. 348. Fig. 349.
Dieffenbach Arm-flap Method.