“I cut an osteo-cutaneous flap from the middle of the forehead, of a size proportional to the size and shape of the nose. Its pedicle between the eyebrows is two or three centimeters wide; it widens out superiorly to form seven to nine centimeters. It is triangular, and its base lies near the hair line. In cutting it out, preferably a little large, it goes at first to the bone, through skin and periosteum. With a large, sharp chisel, a thin bone plate throughout the whole extent of the cutaneous flap is detached. It is not always possible to make this a plate in one piece; it often breaks or gives off splinters. This is of no consequence, if care be taken not to lose them and to keep them adherent to the periosteum. They are attached as well as possible to the cutaneoperiostitic flap by passing threads crosswise from one edge of the flap to the other over bony surface, as in Fig. 375. The whole flap is then enveloped in iodoformed suture. “The frontal wound I close at the same sitting by sliding large lateral flaps whose upper border follows the margin of the hair as far as the ears. These are freed completely, brought down and stitched, leaving eventually only a linear cicatrix on the forehead. The lateral loss of substance which results is healed by granulation, and the scars concealed by the hair. “At first parts of the bone die; they ought to be expected to fall out; after four, six, or eight weeks the bone is completely covered with fleshy granulation, and adheres solidly to the flap. The prominent granulations are then scratched, or, better, trimmed away with the knife, and the whole surface is covered with Thiersch grafts. “When the flap is thus furnished with skin within and without, it is put into place. I saw the bony plate with a fine-toothed saw from the grafted side; then I model the flap and place it on the loss of substance freshened by turning the grafted surface toward the interior of the nose by twisting its pedicle, as in Fig. 376. The osseous rim of the pyriform opening is uncovered at the moment of this freshening, and the bony edges of the flap are placed exactly on the bony edge of the aperture. The skin of the flap is then stitched at its lower margins to the skin of the cheeks. To preserve the height of the nasal profile and avoid displacing the bones of the nose, the nose is kept in place with a pin thrust through the nose, and furnished at each end with a rubber button. This aids to form the wings of the nose. If a subseptum is needed, it is made by taking from the skin that covers the circumference of the pyriform opening two small flaps, which are dissected from without toward the median line as far as the point where the septum is normally found. “These are stitched at this point, first upon themselves, then to the end of the nose. Three weeks later the pedicle of the frontal flap is cut; it is turned, put in splints, and the stitching is finished.” [Illustration: FIG. 375.—First step.