This gives a triangular flap, the apex lying upon the biceps and having two adherent pedicles at apex and base. The base is now incised at one angle, transversely and again vertically, as shown. This incision liberates the part of the flap intended for one of the ala of the nose. II. Diachylon plasters are placed under the flap to contract the arm wound immediately the bleeding has been arrested. The free angle of the base of the flap is now turned inward and under the attached part of the flap, as in Fig. 348, so that its margin protrudes from the other lateral incision, and its skin surface lying above the plaster. The edges of the flap are now stitched together, and the flap is allowed to lie cushionlike upon itself while the arm wound heals. This requires about six weeks. [Illustration: FIG. 347. FIG. 348. FIG. 349. DIEFFENBACH ARM-FLAP METHOD.] III. The holding of the flap cushion in place by the use of splints of leather held in place by three needles. The latter are moved about, as the shape of the cushion becomes modeled, about every three weeks. The process ends when cicatrization of the flap or the newly formed nose has been accomplished, shown by firmness and contour. IV. The margins of the old nose are freshened; the lateral incisions extend to the root of the nose, where they are united with an upward convex incision. The skin is well raised, gutterlike, from the deeper tissue, to assure of the best vascularity. V. The upper or apex pedicle of the flap on the arm is cut (see Fig. 349), and the thickened roll of skin, or what may now be termed the new nose, is turned down toward the elbow. It is divided along the line where the two margins of skin had been sutured; in other words, it is laid open longitudinally. VI. The nose thus prepared is brought into place before the freshened margins of the old nose and is sutured into place beginning at the root before the sides are coapted. VII. At the end of fifteen days the pedicle attaching the nose to the arm is severed, the angle for the wing being cut slightly larger than that of the other side, which by this time has, of course, undergone full contraction. The subseptum is made out of the square projection folded upon itself, raw surfaces facing, and is brought into place by suturing it into an incision made in the lip at the required point. =Graefe Method.=—This surgeon devotes six steps to his operation, as follows: I. The borders of the old nose are freshened. II. Sutures are passed through the raised skin of the borders of the old nose. III. The flap is cut from the arm after a pattern made one fourth larger than the new nose required, leaving it attached by the small pedicle intended for the subseptum.