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.