. Manual of operative surgery. edges of thebone. Step —Outline and reflect the flapDFE. In forming this flap cut away withthe chisel a portion of the outer table of theskull (G). The portion of bone G is an in-tegral part of the flap DEF, and is of sizeand shape suitable to be inserted into thecranial defect (0). Step 3.—^Insert the graft G into thedefect O, and suture the edges of flap DEF to the bed from which flap ABCwas raised. Step 4.—Implant flap ABC in the bed from which flap DFE was raised. The operation may be modified by exposing the whole area ACDE by raisinga flap of scalp witho


. Manual of operative surgery. edges of thebone. Step —Outline and reflect the flapDFE. In forming this flap cut away withthe chisel a portion of the outer table of theskull (G). The portion of bone G is an in-tegral part of the flap DEF, and is of sizeand shape suitable to be inserted into thecranial defect (0). Step 3.—^Insert the graft G into thedefect O, and suture the edges of flap DEF to the bed from which flap ABCwas raised. Step 4.—Implant flap ABC in the bed from which flap DFE was raised. The operation may be modified by exposing the whole area ACDE by raisinga flap of scalp without periosteum and then filling the defect O by bone takenfrom the area H attached to the periosteum and not to the scalp. Criticism.—During the necessary manipulations, it is difl&cult to keep theflap of bone from becoming detached from the pericranium. The pericra-nium normally has little or nothing to do with the nutrition of the bone. Thescar in the Miiller-Konig operation is extremely uncouth. While the author. Miiller-Konig operation. 12 THE SKULL AND THE BRAIN has successfully used the method, yet he considers free transplantation of bonefar easier, at least as successful and theoretically much preferable. Ropke (Zent. fur Chir., No. 35, 1912) has used a part of the scapula in thefollowing manner: 1. After exposing the cranial defect by reflecting a flap of scalp, excise thescar tissue over the brain and vivify the edges of the bone. Temporarily packthe wound with gauze wrung out of hot water. Apply dressings. 2. Place the patient on his right side and pull the left arm forwards. Makean incision about 3^ inch to the outer side of the vertebral border of the scapula,exposing the fascia covering the infra-spinatus. Divide the fascia and infra-spinatus just external to the vertebral border but do not divide the a sharp knife dissect outwards, cutting the infra-spinatus from the bodyof the scapula until an area of the bone is exposed fully as large or


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