the adjacent sound skin and relieved the tension on the left side of the neck.

Second Operation, eleven weeks after the first, to remedy the deformity of the lip, which would be difficult to describe, but can be readily understood on inspection of the patient, whom I will show after the reading of this paper.

Third Operation, six weeks from the second. The sloughing of the extremity of the first flap left a considerable granulating surface under the chin, and the cicatricial tissue to the right of the median line still remained. The patient was etherized with difficulty, as usual. A careful and almost bloodless dissection was made, relieving the tense bands under the chin and front part of the neck. A large flap was then taken from between the breasts and over the sternum, extending down to the junction of the latter with the ensiform cartilage, the pedicle being over the clavicular portion of the pectoralis major at the end of the clavicle. It was turned up and fastened into place by silver sutures, and the wound from which the flap was taken closed. None of the transplanted skin sloughed, and four weeks later the wounds were healed, except a small granulating surface the size of a silver quarter. There was now an almost continuous band of sound skin running round the neck like a collar, but not of sufficient width to relieve the tension entirely.

Fourth Operation, four weeks after third. Several bands of cicatricial tissue which remained low down on the neck near the clavicle were divided, and an open wound about three inches long was made. This was filled by taking a flap from the left axilla and upper and outer portion of the left breast, and turning it up below and somewhat between the two other flaps, thereby propping them up and overcoming the tension, so as to allow an erect position of the head at the same time with closure of the mouth. Silver sutures were used to fasten in the transplanted flap, and the edges of the wound in axilla were drawn together. Adhesive plaster was placed around the body to support the edges of the wound in the axilla. Hot-water dressings were applied to the wound so as to keep the flap warm. No sloughing. Wounds healed well, and the patient was discharged six months after entrance, to return in a few months for a final operation.

Fifth Operation. The patient entered the hospital again seven months after discharge. The chin was drawn down by a V-shaped cicatrix, having its apex upwards, with soft and yielding skin on its sides. The V-shaped cicatrix just mentioned was first dissected out, so as to divide all the cicatricial tissue. On the side of the neck, just back of this and under the ear, there was a loose fold of skin formed by a wrinkle in the flap which was turned up from the scapular region in a previous operation. The skin was dissected up from the first incision

backwards to the fold mentioned, which was split so as to be unfolded. This allowed the flap to be brought forward to cover the wound made by removing the cicatrix. The edges were adjusted by fine silver sutures. A compress wet in warm carbolized water was applied, to be changed every hour, and the parts were kept warm by being covered with cotton batting. After the operation there was no perceptible pulse at the wrist, but it soon improved after an enema of brandy. No sloughing occurred, and the patient was discharged from the hospital one month from the date of last entrance and sixteen months from the first operation. The projecting teeth had been extracted and some artificial ones substituted. She was able to hold the head erect and turn

it very considerably to the right. She could keep her mouth closed, and there was no dribbling of saliva. There was not the slightest granulating surface left of all the large wounds made.

CASE III. Mary D., aged forty-eight, three months previous to admission to hospital was burned, slight cicatrices resulting on each elbow, wrist, leg, and breast. There was one on the left side of the face and neck, extending from behind the left ear forwards to just across the median line, which drew down the chin and jaw, and depressed the left side of the mouth slightly. The cicatrices were tender, and ulcerated in small patches. Previous to her entrance into the hospital she had been treated by the "stretching method."

Operation under Ether. The tension of the neck was overcome by the thorough removal of the cicatrix from between the body of the jaw above and the sternum and clavicle below. A large flap was taken from the region of the right pectorals and breast, with the pedicle to the outside and just above the sterno-clavicular articulation. It was placed in position and retained by fine wire (silver) sutures along the superior and left borders, the inferior being left free. The subcutaneous fat was so thick that the flap looked like an enormous double chin, but as the vessels are so largely contained in this tissue it was deemed unsafe to pare it off. The whole was covered with hot compresses and cotton batting. The arms were pinioned to the sides to avoid possible traction on the pedicle. The large wound over the front of chest was closed by sliding with silk sutures. The whole flap did well, and the record of the case a month later states that there was complete union throughout the superior and posterior borders of the flap. The lower border was never stitched to skin, and the whole new skin is much reduced in thickness. On the upper edge of the pedicle are two puckers of skin formed partly by old cicatrices and partly by the turning about of the transplanted flap.

Second Operation. The pedicle was cut off, cicatricial lines and puckers were removed, and the newly detached end of flap united to the surrounding healthy skin, and the whole secured by fine wire sut