With the employment of a cheek-flap lining there is the added objection of cicatrization. The use of a flap from the arm is complicated and requires considerable time for the completion of the operation, and there is always the added danger of infection and consequent death of the osseous plate. To overcome these many difficulties von Mangold advocates the use of a section of cartilage to support the anterior prominence of the nose. It has been found, since the first attempt of and the successful result obtained in 1897 by this surgeon, that cartilage to be used for this purpose should be taken from the costal cartilage, where a strip of the required length and width can be obtained. The results thus far recorded are excellent, and much is hoped for from this method, especially in the reconstruction of loss about the wing of the nose in partial rhinoplasties, where the convexed contour may be reproduced to a nicety. The first attempt to support the flap for a total rhinoplasty by this method was made in 1902 by Charles Nélaton. The use of cartilaginous supports may be combined with any of the methods given heretofore. The flap containing the cartilage may be lined or unlined. All tissue found about the old nose should, of course, be utilized to give added support and to reduce as far as possible extensive secondary cicatrization. The combined Hindu and Italian methods give splendid results, the frontal flap and its support being brought down from the forehead, raw surface outward, and the arm or forearm flap being placed immediately in front of it. The frontal flap with the support requires a preliminary operation to permit of the attachment of the cartilage. Fortunately, this step requires but little time and shows a very slight disfigurement during this period. The secondary wound at the site of the cartilage excision requires little attention and heals readily, and the cicatrix involved is very small. Steinthal proposes taking the flap and cartilage from the thoracic region, grafting it during the preparatory period to the forearm, from which it is transplanted to the face at a second sitting. There is the objection to this method that it requires the arm to be retained in position for a very long time. The author advocated the use of an arm flap made by the Italian method to line the one to be brought down from the forehead in cases of total rhinoplasty where little or no tissue can be obtained from the remains of the old nose. Such procedure reduces the time required by the Steinthal method to one half, and therefore greatly lessens the discomfort to the patient. The fundamental principles as laid down by Nélaton are excellent, and may be applied to any modification of method the surgeon may decide upon where a section of costal cartilage is employed to support the flap, whether this be taken from the forehead, other parts of the face, or remote places. The procedure of Nélaton is as follows: