Holders with cup jaws serrated at different angles are of no value, unless other needles are used with them, as they invariably break the flat ones. To overcome the necessity of rethreading or the use of many needles, the very ingenious holder with ligature carrier can be used, especially where the surgeon does not care to sew with a long, free thread. The silk can be sterilized on the metal spool separately and inserted within the handle of the holder, as shown in Fig. 43. METHODS IN PLASTIC OPERATIONS THERE ARE FIVE DISTINCTIVE METHODS EMPLOYED IN PERFORMING PLASTIC OPERATIONS: I. Stretching of the margins of the skin. II. Sliding flaps of adjacent skin. III. Twisting pedunculated flaps. IV. Implantation of pedunculated flaps by bridging. V. Transplantation of nonpedunculated flaps or skin grafting. This classification differs from that heretofore generally given in the meager literature on the subject, but the author believes his arrangement to be more scientifically exact as well as simpler for recording and history purposes. I. STRETCHING METHOD In the stretching method the defect is neatly excised, so as to freshen the margins to be brought together. It may be necessary, if the defect is too large for free apposition, to dissect the skin away from the underlying tissue to render it more movable and to overcome tension. The shape of the incision depends largely upon the nature of the defect and must be made with a view of leaving as little scar as possible. Where the defect is somewhat _linear_, or elongated, an elliptical incision (_A_) is made, as in Fig. 44, and, if necessary because of too great tension, the skin is undermined sufficiently to allow the parts to come together; if this cannot be done readily, two semilunar incisions (_b_, _b_) must be added. This will allow of ready coaptation. The wound is then brought together with an interrupted suture, appearing as in Fig. 44_a_, the semilunar spaces being allowed to heal by granulation. [Illustration: FIG. 44. CELSUS INCISIONS.] [Illustration: FIG. 44_a_. CELSUS RELIEVING INCISIONS.] In excisions in small rhomboidal form, the skin is merely dissected up and around the wound, the same as in Fig. 45, and the wound is sutured in linear form, as shown in Fig. 46. [Illustration: FIG. 45. RHOMBOID EXCISION.] [Illustration: FIG. 46. UNION OF RHOMBOID EXCISION.] If the defect is oblong in form, the angles are brought together wholly, leaving a small surface to granulate, as in Fig. 47, or they are drawn toward the center, leaving the remainder of the parallel lines to be sutured, as shown in Fig. 48. [Illustration: FIG. 47. OBLONG EXCISION.] [Illustration: FIG. 48. COAPTATION OF SAME.] Another method of overcoming a smaller defect of similar form is to excise a small triangular portion of skin at either side of the oblong, as in Fig. 49, and then with or without dissection bringing the margins together in linear form, as in Fig. 50.