The lining flaps are taken from the nasogenian furrow, placed and sutured as just described, without twisting of their pedicles, and are sutured at the median line and at their free ends to the freshened septal stumps. The Italian flap is placed over those two flaps immediately, or the Italian flap is first made to unite to the raw margin of the defect, and the two nasogenian flaps are made and employed at a later sitting by subplanting. The Italian flap may be taken from the arm or forearm, this surgeon preferring the forearm. The attached flap and position of the hand on the forehead where it is retained with an apparatus for the required time is shown in Fig. 415. The adherent Italian flap and its subseptal addition and the outlines for the lining flaps are shown in Fig. 416. The secondary nasogenian wounds reduced by suture and the flaps so obtained are shown in Fig. 417. The subseptal section of the Italian flap is raised to show the disposition of the flap ends to form the new septum. The raised flap is brought down and sutured to the raw edges of the two septal flaps covering the median cicatrix, its own cicatrices falling within the rim of the nostrils. [Illustration: FIG. 415.—Attachment of flap from forearm. FIG. 416.—Forearm flap in position and outline of lateral flaps. FIG. 417.—Disposition of lateral flaps. CH. NÉLATON METHOD.] This surgeon advises in less severe losses of tissue to do without lining the Italian flap, but to make the latter large enough to be able to fold in enough of its base sections to line the nostrils to the extent of the inferior line of the mucosa. The flap should be cut one fourth longer than the nasal deformity. This procedure also overcomes to a great extent the shrinking of the nasal orifices. The pedicle of the flap is cut close to the arm at the end of two weeks. The subseptum may be made at once if the flap shows good nutrition, as evidenced by marked bleeding at the time of cutting away the bridge tissue. RESTORATION OF THE ALÆ The method of restoration of the wing or wings of the nose depends largely upon the extent of the tissue loss. The use of the Hindu method is not advisable, since the flap must be made with a long pedicle, which involves the making of a large wound and predisposes to consequent large cicatrices, although many surgeons have resorted to the method. The author does not see any advantage with this method, even if the loss of tissue about the lobule is great.