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].
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: