The flap is twisted upon its pedicle and sutured to the skin of the lobule; to facilitate this the left incision is made higher than that on the right. The pedicle may be cut as with all such flaps, and it may be allowed to remain, if not too disfiguring. The secondary wound of the upper lip is drawn together by suture, as shown in Fig. 461. The mucosa of the nose is to be sutured to the raw edge of the flap when that is possible. [Illustration: FIG. 460. FIG. 461. DUPUYTREN METHOD.] =Serre Method.=—This author advises dissecting up a flap from the upper lip, including the skin only, leaving it attached just above the vermilion border, as in Fig. 462. The free and upper end is sutured to the lobule. When union has taken place, the pedicle is divided and is brought upward and sutured into place. The secondary wound repaired by suturing finally. There is some difficulty in dressing the wound during the time required to have it unite to the skin of the lobule, because of the danger of pressure and consequent gangrene. [Illustration: FIG. 462.—SERRE METHOD.] =Dieffenbach Method.=—This author took up the skin flap transversely or obliquely, as shown in Fig. 463, and twisted it into position, as shown in Fig. 464. The objection to the direction of making the flap in this manner is that the consequent cicatrization has a tendency to draw the mouth out of its normal position on the wounded side. [Illustration: FIG. 463. FIG. 464. DIEFFENBACH METHOD.] The following methods show the taking of the flap from the skin of the nose itself. Unless the defect be very small such methods are objectionable. [Illustration: FIG. 465.—HEUTER METHOD.] [Illustration: FIG. 466.—SZYMANOWSKI METHOD.] =Szymanowski Method.=—In the latter method of Szymanowski the flap must be stretched considerably, to close over a lengthy deformity, encouraging gangrene. The deformity is not so great, however, as with the two preceding methods. [Illustration: FIG. 467. FIG. 468. SZYMANOWSKI METHOD.] The author believes a nonpedunculated flap with or without a cartilaginous support should be tried before other methods are resorted to, in all cases, with the hope of healing the graft in place. The fact that the mucosa can in some cases be sutured to the margins of the flap adds much to the possibility of its subsequent life by adding its nutriment to the graft. CHAPTER XVI COSMETIC RHINOPLASTY The operations herein considered have to do with overcoming deformities, congenital or acquired, as a result of traumatism, and in which there is no loss of tissue, the sole object being to give to the nasal organ a more desirable size and contour. There are many types of abnormalities involving both the size and shape of the nose. Some of these deformities may be readily corrected by subcutaneous or submucous operations, while others involve more or less cutting of the skin.