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.