The defect being at a distance from the forehead, the employment of frontal flaps for the restoration of the lobule and alæ are to be eliminated; furthermore, such methods would involve the incision and dissection of the healthy skin of the nose to no advantage but disfigurement, and possible further loss of the organ.
The results with autoplasties about this part of the nose are usually excellent, and particularly gratifying are those obtained with the Italian method, in which the flap is made from the skin of the forearm.
French methods involving large nasogenian flaps are not to be used because of their consequent retraction and cicatrization of the cheeks. Small lining nasogenian flaps may be utilized where necessary, since they cause little scarring.
If the loss of tissue is very small, the flaps to reform the parts may be taken from the nasal skin and the septum be made of a flap from the upper lip. Both such secondary wounds could be drawn together by suture, leaving slight linear scars. Operations of this nature will be described separately later. Some of the methods referred to might be combined for small defects of this nature.
Defects of larger extent may be corrected as follows:
Küster Method.—A flap of considerable size is outlined on the skin of the arm and cut laterally, leaving it attached at both ends in bridge fashion.
Gauze dressings are inserted under the flap. Several days later the superior pedicle is severed and the flap is sutured to the freshened margin of the nose. An application of borated vaselin on gauze is used as the dressing. The arm is held in position by a proper apparatus, a plaster-of-Paris fixture being used by the author.
Six days later the brachial plexus is divided to half its width, and totally divided three days thereafter.
Fifteen days later the free border of the flap is divided into three sections, the median one being made narrowest. The outer small flaps thus made are sutured to the remaining wings of the nose.
Five days later the septum is formed of the remaining unattached flap, which is sutured to the stump of the old septum. It is not folded upon itself, but allowed to heal by cicatrization.