Later Neumann Method.—An incision is made to circumscribe the remains of the old nose at either side, extending upward in rectangular form above the root of the nose, between the inner canthi and upward, and somewhat above the eyebrows, as shown in [Fig. 398].
This flap thus outlined is freely dissected down to the bones of the nose, leaving it attached only at the roots of the wings, so that it can be turned downward, hanging over the mouth, like a curtain.
A deep transverse incision is then made through the remaining cartilaginous structure of the nose, just below the inferior borders of the nasal bones. This gives a cartilaginous, archlike support to this part of the flap, which is utilized to give firmness and shape to the base of the new nose.
The incision just mentioned is depicted in [Fig. 399], in which is also shown the turned-down flap.
After the hemorrhage has been controlled the flap is turned upward and into such position as to form the new nose, utilizing the cartilaginous arch, above referred to, to the best advantage to give the proper contour. This will lower the apex of the flap considerably. The lateral borders are sutured to the freshened margins where possible, but as a rule an opening is left at either side, communicating with the inner nose, which must be healed by granulation.
The wound on the forehead may be brought together completely by suture. The appearance of the nose assumes at this time the form shown in [Fig. 400].
The objection to this method lies in the fact that the cartilaginous arch brought down with the flap is usually insufficient to give proper support to the base of the nose, permitting the lobule to contract and sink. In most cases there is an absence of sufficient cartilage to employ the method at all. An osseous arch would, therefore, preferably be incorporated with the flap, taken from the remaining nasal bones.
Fig. 398. Fig. 399. Fig. 400.