SURGERY. 215 
be constructed of wax or clay; this measured with 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 the 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 grocves 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 smoothly.. (Pl. 189, fig. 21.) 
This mode of operating has experienced various modifications by different 
surgeons. P/. 189, 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 Dieffenbach, 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. Greefe has invented a special apparatus for connecting the 
arm and face, consisting of a cap, jacket, and arm bandage, shown in pi. 
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, d, 
for holding the wrist. Opposite threads are attached to the cap, which are 
tied together to hold the bandages, p, q, 7; two are at g, two at c, and two 
on the other side of the head opposite to g. A small ring is fastened at f 
with strong tape, and through it passed a bandage, by which the entire head 
may be drawn back towards &, if necessary. The cap is attached to the 
jacket, b, at wu. A second ring is placed at 7, for the purpose, by means of 
a tape, of drawing the arm towards tke 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, J, m, n, 0, with six side bands; the 
former consists ef a part for the upper arm, s, 7, and the forearm, s, 2. The 
arm portion is attached along the border, m, 0, to the three side bands, 9, g, 7, 
by nine narrow tapes or silk strings; the same arrangement exists on the 
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