IV. The sutures where required are now passed through the flap, having already been placed through the old nasal borders and left untied. The forearm is drawn against the forehead and the arm is fixed in place with the retention apparatus. The sutures are now tied. They are allowed to remain in about four or five days, not long enough to irritate. V. About the tenth day the head apparatus is removed and the pedicle of the arm flap is divided. The arm may now be carefully lowered to its normal position. VI. The subseptum is not formed from the free end of the attached flap for several weeks. It is then divided by two parallel incisions directed outward. The septal section is folded upon itself, and inserted and sutured in place into an incision made into the upper lip. =Szymanowski Method.=—This author advises making the base of the flap sufficiently wide, and of the form shown in Fig. 350, to permit of the three sections of skin of this part of the flap to be folded upon themselves before being sutured in place at the base of the nose, so as to form lined nares and a thickened and supportative subseptum. [Illustration: FIG. 350.—SZYMANOWSKI METHOD.] =Fabrizi Method.=—This author utilized the immediate method of flap fixation, but makes his flap of triangular form from the inner and upper skin of the forearm. The transverse base is made to lie one half inch below the radio-ulnar space. The flap should be about three inches long and of about the same width. It is cut while the forearm is relaxed; bleeding is controlled by gentle pressure. In the meantime the cicatricial tissue of the old nose margins has been removed and the skin freshened to receive the flap. To approximate the parts, the hand is laid palm down upon the shoulder; the resultant position of the arm and forearm are retained by bandages. The parts are now sutured. On the thirteenth day the line of division is traced out upon the arm with nitrate of silver, at the same time giving the flap somewhat the form required to give the nose its contour. The next day the pedicle is cut and the arm is brought back into its normal position. With the division of the pedicle he advises including a portion of the aponeurosis and a few fibers of the supinator longus muscle. The flap is allowed to remain free at its base until contraction and cicatrization have been established, when the subseptum and wings are made. The position of the arm and the attached flap at the root of the nose is shown in Fig. 351. He advises, when possible, to dissect up a flap of the cartilage of the old septum, letting it adhere at its lower border and turning it from below upward with the skin which covers it to form the subseptum. This will help to hold up the point of the nose firmly (an important matter because it is at this point that all noses constructed of skin flaps alone sink down for the want of suitable prop of tissue).