The free flap is stitched to the stump with several silk sutures. After bleeding has been controlled, a few layers of borated gauze are introduced under the flap to prevent its reattachment and to encourage its thickening, and the entire site of the operation dusted over with an antiseptic powder, and covered with loose folds of sterile gauze. A bandage can be lightly applied over the whole to keep the parts in place.
The success of union of the flap depends upon the immobility of the parts while healing is taking place. The patient is to rest at night in a semirecumbent position with the head held down firmly on the uninjured side with the aid of a tight-fitting linen cap made for the purpose and tied by attached tails of the same material to the bed in such a way that the head cannot be turned during sleep, yet allowing of more or less movement in either direction, never enough, however, to cause tension in the flap. During the day the patient should be on his feet as usual, since the operation is hardly severe enough to compel absolute rest.
As soon as the union of the flap to the ear has been established, which is about the eighth day, the sutures are carefully removed to avoid irritation, but the pedicle of the flap is not to be severed until the tenth or fifteenth day, when satisfactory circulation has been established.
The flap when severed will shrink more or less, but will be seen to be somewhat thicker than when dissected up in the primary operation.
Nothing should be done for a few days hereafter except to keep the granulating surfaces of the flap and back of the ear aseptically clean and healthy.
As soon as the flap loses its pale color and takes on a pinkish glow it may be deemed safe to cover the granulating or secondary wound on the head with grafts of skin, using whatever method most suitable for the purpose. The transplantation of a single flap of skin taken from the anterior border of the arm is perhaps productive of the best result.
To assure of success the graft may be healed under the blood dressing; the methods for which have been fully described heretofore.
Once the secondary wound is healed the surgeon’s attention must be given to the flap attached to the stump. By the aid of the judicious use of the nitrate-of-silver pencil certain parts of this flap may be stimulated to become thickened.
The upper or outer border of the flap should be taken under operation first to form the new helix of the ear. This can be done by making several incisions along its free edge and gently turning backward these small flaps so that their raw surfaces face that of the flap.
This procedure, if neatly done, will eventually give a thickened border to the superior rim.