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.
Fig. 369.—König Method.