SURGERY. 215 



be constructed of wax or clay ; this measured witli strips of paper, and the 

 outlines thus obtained marked off on paper and cut out. This outline is 

 then to be spread out flat on tlie forehead, the base uppermost, the apex at 

 the top of the nose, and marked out on the forehead with ink. Dots of ink 

 should also indicate where the sutures are to be made, four on each side 

 being usually sufficient. The operation itself presents four stages. In the 

 first, the margin of the outline on the forehead is to be cut through, except- 

 ing the narrow neck between the eyes, and the flap of skin dissected from 

 the periosteum. When the bleeding has ceased, the flap is to be twisted 

 on itself, and its edges fitted into the grooves made for its reception, and 

 these fastened with sutures. A roll of oiled lint is then to be introduced 

 into each nostril, for the purpose of supporting the nose, and a pledget 

 above the septum ; the wound on the forehead filled with dry lint ; and the 

 ligatures removed after from forty-eight to seventy-two hours. After 

 adhesion has thoroughly taken place, the twisted strip of skin by which the 

 connexion with the forehead was maintained, is to be cut through, or a little 

 strip cut out, so that it may be laid down smooth!}-. {PI. 139, fig. 21.) 



This mode of operating has experienced various modifications by different 

 surgeons. PL 139, fig. 24, represents the method adopted by Delpech 

 in a particular case ; fig. 25 is the flap of skin brought down and then 

 twisted. 



Fig. 22 exhibits a newly formed nose, after Dieflfenbach, in which all the 

 hard parts had been lost, and the soft parts either destroyed by suppuration, 

 or fallen in. The soft parts were first trimmed off even, and dissected out 

 to a slight amount beneath the skin of the cheeks, and a transverse incision 

 made in the upper lip to receive the septum ; after this the flap was 

 brought down from the forehead and attached as before described. Some 

 surgeons prefer to form the septum of the nose by a subsequent operation 

 from the upper lip. 



When the nose is to be formed out of the skin of the arm, a model of it 

 is to be made, and the surface of the model cut out in paper and marked 

 off" on the arm. Grajfe has invented a special apparatus for connecting the 

 arm and face, consisting of a cap, jacket, and arm bandage, shown in ^^Z. 

 139, fig. 26. The cap, a, is prolonged on each side in a flap, c, by means 

 of which it is fastened under the chin. Above is sewed to it the bandage, f/, 

 for holding the wrist. Opposite threads are attached to the cap, which are 

 tied together to hold the bandages, p, §•, r ; two are at ^, two at c, and two 

 on the other side of the head opposite to g. A small ring is fastened at / 

 with strong tape, and through it passed a bandage, by Avhich the entire head 

 may be drawn back towards Z;, if necessary. The cap is attached to the 

 jacket, J, at u. A second ring is placed at i for the purpose, by means of 

 a tape, of drawing the arm towards the left, if required ; another is situated 

 on the right side. The pantaloons are fastened to the waistband, h. The 

 arm bandage consists of the linen band, Z, 7n, ??, o, with six side bands ; the 

 former consists of a part for the upper arm, 5, w, and the forearm, s, I. The 

 arm portion is attached along the border, ?/?, o, to the three side bands, p^ 5-, 7-, 

 by nine narrow tapes or silk strings ; the same arrangement exists on the 



921 



