An unusually large flap was required to do this, since it had to overcome the greater curvature already given and added to by the arm flap, necessitating an extensive secondary wound. The reverse order of procedure would be the more advisable for this reason, and is resorted to by the following: =Berger Method.=—This surgeon makes the lining flap from the forehead. The secondary wound is at once closed. A flap is then made from the arm by the Italian method, and brought into place before the one just made. It should be of sufficient size to allow of building the base of the nose, which is done not later than three weeks after the pedicle of the arm flap is severed, which may be done at any time between the eighth and the twelfth day. All the precautions are used as already given in the description of the Italian method. The arm is held in the position shown in Fig. 365. Berger sutures the arm wound before bringing the flap into place upon the face to overcome the discomfort of suppuration to the patient. The apparatus is fixed definitely after the patient has recovered from the anesthetic. Great care is exercised to prevent coryza from exposure. Dressings are made twice daily. The pedicle is cut under local cocain anesthesia. To make the subseptum and wings of the nose, the base of the flap is cut into three sections. The posterior surface is freshened and the parts are folded upon themselves and sutured into position. Instead of employing rubber tubes, he resorts to a specially devised apparatus to retain two metal tubes in the nares, and at the same time make gentle pressure to the sides of the nose to mitigate the columna contraction. The latter is planted into a V-shaped incision made into the tissue of the upper lip at the proper place of attachment. The subseptum may be lined with a flap of mucosa dissected up from the floor of the inner nose. For the wings of the nose, such tissue as may be of service to give them stability and structure is taken from the remains of the old nose. [Illustration: FIG. 365.—BERGER METHOD.] The apparatus just mentioned and shown in Fig. 366 is used from the very first day until total cicatrization has taken place, and even for a longer period to aid in shaping the entire nose and the tendency to collapse has been overcome. [Illustration: FIG. 366.—BERGER RETENTION APPARATUS.] =Szymanowski Method.=—A frontal flap, divided along the median line and shaped as outlined in Fig. 367, is made from the forehead. Two triangular flaps are then raised from either side, and including the angle of the nose as shown. The divided frontal flap is now brought down in such manner that their raw surfaces meet, thus forming a vertical septum. The margins are united by suture, and the lower ends are fixed into a wound made for the purpose at the base of the nose, as shown in Fig. 368, to form the new subseptum.