The flap is then enveloped in iodoform gauze, and the head, forearm, and arm are fixed in plaster of Paris, the forearm being bent at a right angle to the arm (see Fig. 387). [Illustration: FIG. 387.—ISRAEL METHOD. Position of forearm for placing of flap.] After nine days the osseous connection still remaining is severed, and the nose is modeled upon the forearm, as heretofore described in these operations, this surgeon using silver wire to retain the parts. The raw skin surfaces are allowed to heal upon each other and the flap is permitted to come in contact with the wound on the forearm temporarily, to which it might adhere, the gauze being now removed. After twelve days the newly modeled nose is freed from such adhesions and kept from healing to the parts by using dressings between the flap and wound. Five days after, the margins of the old nose are freshened in the form of an inverted V. If there be sufficient cicatricial tissue it is turned down, raw surface out, to line the new nose. A prolongation of the pedicle is now cut, widening out toward the radial side of the arm, made obliquely, as shown, so that its pedicle now corresponds to a width of seven centimeters. The whole flap except this newly formed pedicle is cut free of this forearm. The arm is put into the position shown in Fig. 387, and the freshened flap margins at the root, the whole length of the left side, and part of the upper right lateral. The plaster dressing to hold the arm in the proper position until complete union is established is used. This done, the pedicle is cut, and such minor operations are done to fix the remaining free margin and the base of the new nose. CARTILAGINOUS SUPPORT OF FLAP The methods just described in which an osseous plate of various size and form is included with skin flaps for the restoration of the nose give undoubtedly the best rhinoplastic results. The new nose is given not only better shape, but a permanency of such form that skin flaps of themselves could never give. The unfortunate factors in these osteo-cutaneous operations are the many difficulties experienced. The cutting or making of the bony plate is no simple task. The skin is an uncertain agent to employ, because of the peculiar contour of the bony surface from which the plate is to be removed. The chisel, no matter how dexterously used, is liable to cut through the entire bone thickness, which has occurred in several recorded cases. There is also the possibility of necrosis of a part or all of the bony plate thus obtained, and where the latter is not lined interiorly there is the added danger of infection. Furthermore, the secondary wound is more extensive; the bone exposed requires about a month’s time to granulate over before skin grafts can be successfully applied over it.