[Illustration: FIG. 408.—First step. FIG. 409.—Making lower nasal flap section. NÉLATON METHOD.] The saw is made to sever the nasal bones from the apophyses of the superior maxillary. The blade follows a line starting one centimeter anterior to the anterior and superior nasal spine, and is directed downward toward the second molar, not going entirely through the apophyses. The latter are broken with the chisel in such way that some of the bony border lies in contact with the nasal process of the superior maxillary. This fracturing is made as the flap is still further brought down, as in Fig. 410. The flap is now so adjusted that its median bone-lined section will form the median third of the nose, the base being made by folding the flap upon itself, as shown in Fig. 411. [Illustration: FIG. 410.—Forming base of nose. FIG. 411.—Ultimate disposition of entire flap. NÉLATON METHOD.] The raw surfaces are sutured at their point of coaptation, laterally, and to the margins of the genian flaps. The frontal wound is brought together by suture as closely as possible, and Thiersch grafts are employed to close any wound still remaining. The objections to this operation is that of all bone-plate flaps. A flap containing a cartilaginous support taken from the eighth costal cartilage, as previously described, would undoubtedly give the best results. RESTORATION OF LOBULE AND ALÆ The defect being at a distance from the forehead, the employment of frontal flaps for the restoration of the lobule and alæ are to be eliminated; furthermore, such methods would involve the incision and dissection of the healthy skin of the nose to no advantage but disfigurement, and possible further loss of the organ. The results with autoplasties about this part of the nose are usually excellent, and particularly gratifying are those obtained with the Italian method, in which the flap is made from the skin of the forearm. French methods involving large nasogenian flaps are not to be used because of their consequent retraction and cicatrization of the cheeks. Small lining nasogenian flaps may be utilized where necessary, since they cause little scarring. If the loss of tissue is very small, the flaps to reform the parts may be taken from the nasal skin and the septum be made of a flap from the upper lip. Both such secondary wounds could be drawn together by suture, leaving slight linear scars. Operations of this nature will be described separately later. Some of the methods referred to might be combined for small defects of this nature. Defects of larger extent may be corrected as follows: =Küster Method.=—A flap of considerable size is outlined on the skin of the arm and cut laterally, leaving it attached at both ends in bridge fashion.