..

Chapter 1

The principles and purpose of plastic

surgery-past and present
M. Felix Freshwater, M.D.

The principles and purpose of plastic surgery

are related intimately. Rather than being mesmer
ized by memorized facts of so-called historical
irsts, we should understand the development of
plastic surgery in terms of accepted principles of
historical investigation. Similarly, instead of per
forming plastic surgical procedures blindly, we
should understand the principles which allow us to
be creative both in the practice of the art and in
the design of solutions for plastic surgical prob
lems. In the solution of these problems, we must
have purposes and goals for the patient, the sur
geon, and society.
THE PAST

Standing at the three-quarter mark of the twen

tieth century, two of the most exciting recent de
velopments of interest to plastic surgeons have
been replantation surgery and the neurovascular
island Aap. However, historical research reveals
that both replantation of digits and use of the
neurovascular island Aap were developed early in
the nineteenth century. What is the signiicance of
this? ( Is this merely another example of the ad
monition that someone who thinks that he has in
vented a new surgical procedure simply has not
read the German literature? ) Seeking historical
irsts by deciding who irst described disease X or
performed procedure Y or tried technique Z is
doomed to failure because one can never be posi
tive that a given person described, performed, or
tried something before everyone else. Instead it is
wise to adhere to the principles of priority best
expressed by Sir Francis Darwin and Sir Richard
Owen. It was these principles that Sir William
Osler used to decide who deserved credit for the

discovery of general anesthesia. Owen said, "He

becomes the true discoverer who establishes the
truth; and the sign of the proof is the general ac
ceptance."22 Darwin said, " In science, the credit
goes to the man who convinces the world, not to
the man to whom the idea irst occurred. Not to
the man who inds a grain of new and precious
quality, but to him who sows it, reaps it, grinds it,
and feeds the world on it."10 Let us examine the
development of the neurovascular island Aap and
inger replantation in terms of Owen's and Dar
win's principles.
The neurovascular island lap

At irst glance, it might seem that the history of

the neurovascular island Aap is the history of the
vascular island Aap. The vascular island Aap
evolved from the work of Theodore Dunham11 of
New York, George Monks21 of Boston, and Jo
achim Von Esser28 of whatever country he hap
pened to be traveling through at the moment. In
1893 Dunham described a two-stage operation: in
the irst stage, a scalp Aap based on the supericial
temporal artery was raised and implanted into a
defect of the malar area; at the second stage, Dun
ham deepithelized that part of the Aap above the
supericial temporal artery, dissected it away from
the lateral parts of the flap's pedicle, retuned the
lateral parts of the pedicle to the donor site, and
buried the deepithelized Aap in an incision con
necting the malar area to the donor site.
Acknowledging Dunham's work, Monks in
1898 created the one-stage island Aap procedure
with which we are familiar today. As can be seen
in Fig. 1- 1, Monks palpated the course of the
supericial temporal artery, made an mJsJon
3

Bsic principles

Fig. 1-1. Vascu lar isl and flap to recon struct lower eyelid from Monks. (From Mon ks,
G. H . : Boston Med . Su rg. J. 139:385, 1898; cou rt esy
ational Library of Medicine,

Bethesd a, Md .)

through the skin (Fig. 1-1, A), and dissected out

the artery and its surrounding tissues (Fig. 1-1,B).
He created a tunnel between the forehead and
the defect of the lower eyelid as seen in Fig. 1-1, C,
pulled his island Aap through the tunnel (Fig. 1-1,
D), and closed the defect with tissue of the island
Aap (Fig. 1-1, ).
Von Esser (Fig. 1-2) used Monks' island Aap
and performed some variations on it in recon
structing maxillofacial trauma in soldiers during
and after World War I. It was Von Esser who irst
named island Aaps in his paper from the New York
Medicaljoumal of 1917. The neurovascular island

Aap as known today was developed by Littler19 in

the United States and by Tubiana and Duparc27 in
France for use in surgery of the hand.
However, it is abundantly clear that the neuro
vascular island Aap was developed in the early part
of the nineteenth century. Let us trace the events
that led to the development of this Aap. The broad
side shown in Fig. 1-3 was published in India in
1794 and in London in 1795.30 The broadside de
scribes the case of Cowasjee, a bullock driver for
the British Army in India who had his nose cut
off when he was captured by the enemy. A tile
maker from a local caste reconstructed a nose for

--

Fig. 1-2. J oac h i m F. S. Von Essen. (Cou rtesy N ation al

Library o f M edici ne, Beth esda , M d . )

111'.. . , , _

;_
--

\.,.

,,,Ar,,

t - ."'. .'

!!'_ .. .It, ... --

()J}R. \TIOX.
.-

....J ... .......

-

Fig. 1-3. Cowasjee broadside by J ames

Wales. (Courtesy N ational Library o f
Medicine , Bethesda, M d .)

F;
-

.tr

Fig. 1-4. A, Preoperative e n graving of Carpue's i rst patie n t. B, I m m ediate postoperative

engaving of Carpue's i rst patient. C, Preoperative and l ate postoperative engraving
ofCarpue's secon d patient. (From Carpue, J. .: A n accou n t of two successfu l operations
for restoring a l ost nose, London, 1 8 1 6, Longman. Hu rst. Rees, Orme, & Brow n ; cou rtesy
N ational Library of Medicine , Beth esda, Mel.)

The principles and purpose of plastic surgey-past and present

Cowasjee using a forehead lap rotated into the
defect, with the donor site being left to heal by
contraction. Records at the India Ofice Library
indicate that several copies of this broadside were
ordered for Sir Joseph Banks, President of the
Royal Society and famous naturalist. 14 Banks was
a close friend of Joseph Constantine Carpue, an
anatomy teacher in London, who became fasci
nated with the broadside-often recounting Cow
asjee's tale to his anatomy students. Carpue8 began
experimenting on cadavers on whom he created
forehead laps and then applied the results of
these experiments to create noses for returning
mutilated veterans of the Napoleonic wars.
In 18 16 Carpue published a book entitled An
Account f Two Successful Opeations for Restoring
a Lost Nose With the Integuments of the Forehead in
the Cses f Two Oicers of Hs Majesty's Army, in
Which are Included Hstorical and Physiological Re
marks on the Nasal Opeation Including Descriptions
f the Indan and Italan Methos. Carpue reviewed
the fact and folklore of plastic surgery up to his
time. In Carpue's book are excellent engravings
by Charles Turner, shown in Fig. 1-4, depicting
Carpue's preoperative and postoperative results.
What is especially striking about these engravings
is the honesty with which they are depicted, show
ing that the patient did not have a perfect lifelike
nose at the end of the procedures. Carpue's book
was an immediate success and led to a renaissance
of reconstructive surgery. Shortly after his book
was published, Carpue became one of the few sur
geons ever to be elected to fellowship in the Royal
Society of London. His book was translated into
German,9 with Carl Von Graefe, Professor of Sur
gery in Berlin, having written a foreword to it.
In 18 17 Von Graefe29 published his own book,
Rhinoplastik, and for the irst time the word "plas
tic" was used to describe a reconstructive opera
tion. Finally, in 1838 Zeis published his Handbuch
der plastichen Chirurgie, 31 which reviewed the litera
ture of plastic surgery up to that time, and with
the publication of this book, plastic surgery was
given its name.
With this brief overview of plastic surgery at
the beginning of the nineteenth century, let us
look at an interesting article that appeared in the
Journal Universal et Hebdomaaire in Paris in 183 1.1
The article was the minutes of the December 19,
183 1 meeting of the Institute of the Academy of
Sciences and Reports and contains a case report
by Philippe Blandin. An abstract of these minutes
appeared in the Medical-Chirurgical Review of
1832.3 This abstract is signiicant for two reasons.

First, it shows that Blandin's report was not buried

in an obscure corner of the medical literature but
was published in another journal in another coun
try. Second, the abstract is a translation from
French into English made in the same era, and
this eliminates errors of interpretation that might
occur in a more modern translation. The abstract
is as follows:
The patie n t , had been l o n g a ffected with an enor
mous cancer of the nose , w h ich had resisted every
treatment. M . B l and i n , having com pletely excised the
diseased part, detached from the forehead a Aap of i n
teg u m e n t , a n d shaped i t to the stu m p of t h e nose; b u t
h e did not d i v i d e the ped icle of the Aap as h a d usu a l l y
been d o n e ; i n stead of doi n g th is, h e separated the ski n
from i t a n d then c u t away t h e i nt e g u ments from the
root of the nose; the opposite raw su rfaces were b rou g h t
together, and quickly u n i ted. By t h i s maneuver, the n e w
nose conti n u ed to reta i n its com m u n ication with the
blood vessels and nerves, w h i c h i m parted l i fe to i t at
i rst, and was thereby m uch stronger and l ess l i kely to
be a ffected by col d , and other accidents.*

Thus in 183 1 Blandin (Fig. 1-5) described the

use of the neurovascular island lap. Unlike Dun
ham, Monks, and Von Esser, he purposely men
tioned preserving the blood vessels and nerves
going to the lap to improve function. In 1836
* F rom A nonymous: R h i n o p l astic operation , Med. C h i r.
Rev. 1 7: 1 7 2 , 1 83 2 .

Fig. 1 -5. Phi l i ppe Blandin. (Cou rtesy National Library

of Medici ne, Beth esda, Md.)

Bsic principles

Blandin published his book De l'Autoplastie. 7 The

main points of De l'Autoplastie were that it was ad
visable to preserve the pedicle of the forehead lap
when rotated into place for rhinoplasty because if
this pedicle were to be divided prematurely the
lap would die. Furthermore, if there appeared to
be too much tension when the pedicle was rotated
into place, it was advisable to separate the vessels
from the remainder of tissues in the pedicle and
rotate them separately. Blandin said that by this
maneuver, one could decrease the amount of tor
sion on these vessels and thereby preserve the in
tegrity of the lap. Despite the description of the
neurovascular island lap having been published
in France and knowledge of this publication hav
ing spread to England, there is no evidence that
the use of the neurovascular island lap became an
accepted procedure. Indeed two years before Dun
ham's report, the monumental French Traiti de
Chirurgie12 mentioned the problem of lap necrosis
in forehead laps and suggested the use of an axial
lap made wide enough to include the supra
trochlear artery; no mention was made of the
supratrochlear nerve or vein. Therefore it appears
that Blandin was more than a century before his
time and that this early example of a neurovascular
island lap does not fulill Owen's and Darwin's
criteria for discovery, despite its interest as a plastic
curiosity.

Replantation of digits

The history of replantation surgery is older

than that of plastic surgery. Indeed Saints Cosmos
and Damian, the patron saints of surgery, are
credited with having performed the irst successful
composite tissue homograft in their miraculous
transplantation of an entire lower extremity from
one person to another. The irst example of re
plantation that is often cited is the story told by
Leonardo Fioravanti13 (Fig. 1-6) in his book of
1570, Il Tesoro Della Vita Humana. Fioravanti re
counts an incident that occurred when he was in
Africa. A Spanish gentleman had his nose cut off
in a duel. Fioravanti urinated on the amputated
nose, replaced it in its proper position, and dressed
the wound. About 8 or 10 days later, he removed
the dressing and observed a completely healed
nose. Fioravanti's anecdotal account, like others
that succeeded it, was not believed.16 Realizing
this, William Balfour5 took great care when he sub
mitted "Two Cases, with Observations, Demonstra
tive of the Powers of Nature to Reunite Parts which
Have Been, by Accident, Totally Separated from
the Animal System" to the Edinburgh Medical and
Surgicaljounal in 1814.
Balfour's irst case was that of his 4z-year-old
son who sustained incomplete amputations of the
distal phalanges of three ingers that were crushed
in a door. Balfour's second case was that of George
Pedie, a carpenter, who accidently amputated his
own left index inger with a hatchet. According
to Balfour:
I exam i n ed the w o u n d , and fou n d it began near
the u pper end of the second phalanx, on the th u m b
side a n d term i n a ted abo u t t h e third phalanx on the
opposite sid e. The a m p u tated p iece, as measu red by
the pati e n t h i msel f, was an i n c h -and-a-hal f long, on the
thumb sid e, and a n i nch on the oth er. (The wou n d was
i n fl icted i n the c lean est m a n ner by one stroke o f a
hatch et, and term i nated i n an acute poin t.) About 5
m i n u tes, as nearly as l can guess, Thomas Robertson
retu ned w i t h a piece o f fi n ger, w h ich was wh ite and
cold; I remarked o DL Reid, who was prese n t , that i t
looked a n d fel t l i ke a b i t of ca n d l e. Without t h e loss o f
a moment, I poured a stream of cold water on both
w o u n d ed su rfaces, to wash away t h e b lood from one,
and any d irt that might be ad heri n g from the otheL
I then appl ied, w i t h as m u ch accuracy as possible, the
wounded su rfaces to each oth er, expressi ng a con i d e n t
expression t h a t reu n ion wou ld t a ke place.*

Fig. 1-6. Leon ardo F ioravan ti. (Courtesy National Li

brary of M edici n e, Bethesda, M d.)

* From B a l four, W.: Two cases, w i t h observations,

dem onstrative of the powers of nat u re to reu n i t e parts
w h ich have bee n , by accident, tota l l y separated from
t h e a n i ma l system , Edin. Med. S u rg. J. 1 0 :42 1 , 1 8 1 4 .

The principles and purpose of plastic surgey-past and present

Balfour found that adhesion did take place.
And because, as he said, "It must be confessed,
that instances of the reunion of parts which had
been entirely separated are very rare in the human
body, so rare that most practitioners still treat with
disbelief and ridicule those instances which have
been put on record," he included copies of afi
davits by George Pedie, Thomas Robertson, and
Peter Reid, which were witnessed by Duncan
Cowen, a Justice of the Peace (Fig. 1-7).
Here is an example of the successful replanta
tion of a cleanly amputated inger. What role does
Balfour play in the history of plastic surgery? What
credit does he deserve for the development of re-

Dr Balfour on

tre Rm1ion

f Se>rrall Part1.

429

1, GEORGE PEnm, house-carcntcr, declare, That, onthc Oth

.1y of .June last, when at work 111 the Advocates' J.ihr.rv, 1 occi
.
dcntly struck .oil the inger nxt the thumb .of my left h;,n<l, at
k
e,
wath
a hatche t : 1 hat, ccompanaed lly Thonps
o
str
0
011
Ro
bertson, foreman of the work, I a mm cd iatc ly went to Dr lal
four, who, as soon as he saw what had happened, ikc11 where
. of inger was that had been. struck
1e bat
ol'? That I said I
did not know, but believed it would be found where the acci.

dent happened: That Dr Balfour requested Thomas Robertson

10 go and bring it as quickly as possible : That Thomas Robert
son went and retumed with it in about ive minutes: That Dr
Balfour immediately washed bth it and my bleeding inger with
been struck of and
cold water, and replaced the paece that
bound it up : That Dr Balfour said he expected it would
,cause he had been successfu l in a similar rase eleven years ago,
having replaced three of one of his son's ingers that had been
cut of by accident, and which completely united : That 1 had
11o reason to go to any other than Dr Balfour, but that I did not
believe the part of my inger that had been cut of would re
unite, and that I was laughed at by all my acquaintances for ever
rxpecting that it would : That when the dressings were irst re.
moved, which was on the 12th of June, reunion of the part<
ras found to have taken placo.
And I declare, that the merit of
he cure belongs exclusively to Dr Balfour. All which I declar'
to be truth.
(Signed)
GlORGE PEDIE.

had

Edinhurgh 1

I Sth

Jug

18 14.

adiacrc,

DuNCAN, Co wAN , J.P.

Jug

Edinburgh, 19th
1114, Conpeared Thomas Robertson,
mentioned in the preceding declaration who bein g examined,
declares confcrm to the preceding witness
i\nd
ahis is truth.
THOMAs RoBlRTsox.
(Signed)

in omnibu1.

DuNCAN CowAN, J.P.

I PETlR REm, physician in Edinburgh, declare, that I wos

itness to the facts and conversation stated in the above declarl
tion by corge Pulie; that I ha\'e this day examined his i,gL:,
and inJ that complete reunion has taken place.
(Signed)
PETER Hrm, [.D.
DuNCAN LowA<, J. r.

Suorn hforc

ne, at

Edi1burgh, July 26,

1814.

From the above details, many questions naturlly arise, a:1y o11_c
f which I am far from pretending sati;factorily to answer. It as

impossible,

Fig. 1-7 . A ffidavits from B a l fou r's report. (From Bal

fou r, W.: Ed i n . Med . S u rg. J . 10:42 1 , 1 8 1 4 ; cou rt esy
Nat ional Library of Medicine, B e t h esda, Md.)

plantation of parts? Did his work become generally

accepted as Owen required, and was his idea con
vincing as Darwin required? The answer to these
questions is "yes," as witnessed by the lurry of
activity that appeared in the medical literature
shortly after Balfour published his 2 cases. Exam
ples of partial amputations that appeared are too
numerous to mention. In addition, there were
reports by others of the complete amputation of
the distal phalanges that appear convincing, even
under modern criteria. For example, there is the
case reported by Henry Bailey4 of Bedford, Nor
folk, in the Edinburgh Medical and Surgical Jounal
in 18 15.
Bailey's patient sustained a clean amputation
through the middle phalanx, which was treated by
cleansing and securing the amputated part by
plasters and small splints. At 2 weeks postopera
tively, the nail separated from the replanted digit,
and the patient complained of numbness in the
inger. In addition, the patient was unable to bend
the distal phalanx.
Balfour's work was known not only in England
but was also reported on the Continent as well.
L'Espagnal in France claimed credit for the irst
successful replantation of completely amputated
digits, having apparently misread Balfour's ac
count and having thought that George Pedie's case
was that of a partial amputation. In a subsequent
paper in 18 17 Balfour6 rebuked L'Espagnal and
described how well known his own account had
become:
I received congratu lations on the s u bject , from vari
ous parts of Scotland and E n gl an d , from France, Sw it
zerla n d , t h e Ea st and West I n d ies . . . . Ped ie's case i s
men tioned every season as the fi rst well authent icated
fact of the k i n d , by all the teach ers of a natomy and s u r
gery in t h e school of m ed ici n e , to w h i c h there is an afflux
o f students from every quarter of th e world; (that) it was
recorded in every period ical p u b l icati o n , the su bject of
conversation and o f ad m i ration among a l l ra n k s of peo
ple in the U n ited K i n gdom; (that) it was i n the Biblio
theque de Medecine Britannique and , became known i n
France and Switzerland as i n B ritai n . *

In an interesting twist o f historical events, it

appears that the irst skin graft resulted from Bal
four's work on replantation. In the manuscript
catalogue of Sir Astley Cooper's preparations ap
pears some notes made by one of Cooper's stu
dents during one of Cooper's lecture sessions at
*From B a l fo u r, W.: On t h e irst notice of a re- u n ion
a fter en tire separation of part s, Lo ndon Med . Phys. J .
37:472, 1 8 1 7.

10

Bsic principles

Guy's Hospital. As they appear in the catalogue,

these notes state2:
A copy of the cu rious a n d v a l u abl e papeL H artield ,
a you n g m a n a d m itted i n to G u y's H ospital (Cone l i u s
Ward), A p r i l 9 , 1 8 1 7 , w i t h a d i seased th u m b w h i ch M r.
Cooper, now Sir Astley, a m p u tated between the pha
l n ge s 01 t h e 1 8th o f J u ly. He then c u t off a heal t h y
ptce o f mtegu m e n t from the a m pu tated part and a p
.
phed t t to t h e face of the stu m p w h e re he secu red it by
means of ad hesive s l ips. First week to J u ly 2 5 , u n ion
see m s to have taken place. Second week th-ough August
I , M r. Cooper p roved the vascu lari t y of the newly at
tached portio n by prick i n g i t very sligh tly with the poi n t
o f a lancet w h ich p-o d u ced lu i d loss a s read ily as fro m
a n y o t h e r part o f t h e l i m b , sensibi l ity has not y e t re
t u ned. T h i d week from the o peration , i n the cou rse
of t h i s week sensation was restored in the end of t h e
stu mp. September 2 5 , the stu m p a ppeared qu ite w e l l .
N o t e : t h i s pati e n t , l th i n k , resided in K i tcha m . *

One might think that this case is reason to

credit Cooper with developing skin grafting. In
deed he principle that Cooper used in applying
.
the skm graft, that IS, using the portions of an am
putated part for salvage of the remaining tissues,
was relearned recently in the twentieth century.
However, as with Saints Cosmos and Damian and
Fioravanti, there is no evidence that Cooper's case
as duplicted let alone widely accepted at the
ume. A bnef account of this case was published
by Franz Reisinger25 in the Bayersche Annalen fur
Abhandlungen, Eindungen und Beobachten aus dem
Gebiete der Chirurgie, Augenheilkunst und Geburt
shulte for 1824. Reisinger's account of the case is
buried in a footnote in a paper on experimental
corneal transplantation. The Bavarian Annals was
an obscure jounal that lasted less than a year, and
only one copy is known to exist in the United King
dom and another copy known to exist in the
United States. Therefore, although Cooper's case
of skin grafting was published, he cannot be
credited with having made a signiicant contribu
.
tun to the development of skin grafting. As an
.
aside, It should be mentioned that skin grafting
did not become accepted until it was popularized
by Pollock in 1870. s
PRINCIPLES OF PLASTIC SURGERY

The foregoing discussion should reinforce the

i ea that just s one should not investigate the
history of plastic surgery without adhering to the
fundamental principles of the history of science
* F rom A nonymou s : M S catalogue of S i r Astley Cooper's
.
.
pre paratio n s , H u n tenan M u seu m , Royal Coll ege of
Su rgeo n s , London.

Fig. 1-8. Sir H arold Del f Gillies, ci rca 1 932. (Cou rtesy

D. Ralph M i llard , M . D . )

such a s those of Darwin and Owen, s o one should

not perform plastic surgery without a thorough
understanding of its principles. It is these princi
ples that provide the interface between the sci
entiic facts and the clinical art of plastic surgery.
The year was 1920, and the world was recover
ing from the holocaust, the terror, and the de
struction of World War I. It was a time for assess
ing damage and reconstructing and reforming the
face of an earth that had been mutilated by the
trauma of war. England had been spared from the
sword, and although her soil was not scarred, her
men were. At this time of repair-this time of
healing of the wounds of war-Major Harold Delf
Gillies (Fig. 1-8) was responsible for reconstructing
the horrible deformities of the English forces. Gil
lies17 summarized his experience in his book, Pastic
Surgey of the Face. In the irst chapter of his book,
Gil! ies outlined the principles of plastic surgery,
which developed by trial and error as he perfected
his plastic surgical knowledge and technique. The
following principles are as important and relevant
today as they were when irst published by Gillies
more than half a century ago:
l. Obta i n a h i s tory.
2 . Mi stakes i n d iagnosis due to i nadequate exam
i nation are perhaps the com monest ca use o f
i n d i fferent treat m e n t.
3. Make a record.
4 . A l l ormal tissues s h o u ld be re placed as early as
posstble and maintai ned i n its normal posi tion.

The principles and purpose of plastic surgey-past and present

II

lined in 1920. Following are additional principles

of Gillies20:
I. Plastic su rgery i s a con s ta n t batt l e between beauty

a n d bl ood su pply.
2. Make a plan and a patten for th i s plan.
3 . H ave a l i fe boat; that i s, have a reserve plan.
4. A good style will get you t h wu gh , w h e n w itho u t
i t y o u w o u l d fai l .
5 . Treat t h e primary defect i rst, n o t l etting con
cen for the secon dary d e fect endan ger t h e f i n a l
resu lt, b u t borrow from Peter t o p a y Pau l o n l y
when Peter c a n a fford i t .
6 . N ever t h row a n y t h i n g away.
7. Never let routi ne method become you r m aster;
[ that is, fi t the operation to the pati ent and not
vice ve rsa ] .
8. N ever do today what can honorably be p u t o ff
u n t i l tomorrow-w h e n i n doubt, don 't.*

Fig. 1 -9. D. Ral p h M i l l ard , ci rca 1 95 5 . (Cou rtesy D.

Ralph Mi l l ard , M.D.)

5. In plan n i n g the restoratio n , fu nction is the fi rst

consideration , and i t i s i n d eed fortu nate that the
best cosmetic esults are, a s a rule, only to be
obtained w h e re fu nction has been restored.
6. The re placement s h o u l d be as nearly as possible
in terms o f the tissue lost, i.e., bone for bon e ,
carti lage for cart i l age , fat for fat, etc.
7 . The gai n of the skin in Raps has to be written o ff
agai n st th e loss which occurs w h e n the bed from
w h ich it was rai sed is c losed.
8. Th e factors necessary for the prod uction of the
opti m u m scar are: (a ) asepsis; (b ) avoidance o f
tension on t h e opposi n g sutu res; (c) perfect a p
position of th e skin ed ges; (d ) an often u n k n o w n
person al factor i n t h e pati e n t; a n d (e ) e a r l y re
moval o f the s u tu res (th e opposi n g s u t u res on
the th i rd and fou rt h day, retai n i n g s u tures l e ft
u nt i l their fu nction i s fu l fi l led ).
9. The closest watch i s m a i ntained d u ri n g the
first 4 8 h o u rs u pon t h e site o f the opeation.
I0. Ti m e is the plastic su rgeon's greatest ally a n d
also h i s m o s t trenchant critic.*

After World War I I, Ralph Millard (Fig. 1-9)

visited Gillies and in 1950 published a paper en
titled "Plastic Peregrinations" in which he outlined
what he called the Ten Commandments of Gillies
as leaned at the feet of the master.20 Some of the
Commandments are the same as those Gillies out* From Gi ll ies, H. D.: Plastic su rgery of the face, Londo n ,
Oxford Univcrsit}" Press, p p . 3-34.

1920.

As a result of the collaboration of Millard with

Gillies, the Principles and Art of Plastic Surgey ap
peared in 1957.18 The second chapter of the book
was devoted to principles of plastic surgery. The
principles were a combination of those outlined by
Gillies in 1920, those ascribed to him by Millard in
1950, with some additional principles. These addi
tional principles are as important as their prede
cessors: irst, whereas in 1920 Gillies stated that it
was necessary to obtain a history, by 1957 "Obser
vation is the basis of surgical diagnosis."18 Simi
larly, Gillies and Millard elaborated on what they
meant by a good style. They said that the hall
mark of the style was "dexterity and gentleness,"
and they gave the easily remembered aphorism,
"Do not lean on the patient or lift him by the
stitches!" Another principle, "Do something posi
tive," would appear to be the basis of Millard's
rotation advancement principle. As Gillies and Mil
lard wrote, "When a lacerated lip is a jigsaw puzzle,
look for landmarks, and if you can ind two bits
that deinitely it, put them together-at least you
will have mad e the irst move." Consultation with
other specialists was also emphasized. They said,
"In planning, two heads are better than one. In
execution, gain cooperation of the regional ex
pert." Another important principle was "Speed in
surgery consists of not doing the same thing
twice." And, as the 1957 book itself shows, "Only
by late follow-up can methods be effectively
evaluated," a principle that should be remembered
whenever reading about a new plastic procedure.
The importance attached to these principles is best
*From Mi llard, D. R.: Plastic peregri nations,
Reconstr. Su rg. 5 : 2 6, 1950.

Plast.

12 Bsic principles

seen by a statement made by Gillies and Millard:

"The various principles apply not merely to plastic
problems, but have a basis applicable in a more
general way to a philosophy of life."*
THE PURPOSE OF PLASTIC SURGERY

We have discussed the principles of the history

and practice of plastic surgery, but what is the pur
pose of plastic surgery? Is the goal the satisfaction
of the patient with the end result, or is it the satis
faction of the surgeon in accomplishing the ends to
the result? Is it the gain that the patient achieves
in interpersonal relationships, or is it the gain that
the surgeon achieves in his bank account? As a
mere student of plastic surgery it would be pre
sumptuous for me to pontiicate on the purpose of
plastic surgery. Surgeons much older and wiser
than I have offered their conceptions of the pur
pose of plastic surgery, and I should like to share
their thoughts with you.
Gaspare Tagliacozzi (Fig. 1-1 0), Professor of
Medicine at the University of Bologna in the six
teenth century, who is considered to be the father
of plastic surgery because of his publication of the
irst textbook of plastic surgery, offered a purpose
of plastic surgery that seems to be as relevant today
as it was when it was published in 1597. Taglia
cozzi26 said:
We bring back, refash ion , and restore to w h oleness
those feat u res w h i ch nature gave bu t cha n ce destroyed ,
not that they may charm the eye but that they may be
an advan tage to the l i v i n g so u l , not as a means of arti
i ce, bu t as an a l l eviation of i l l n ess, not as become ch artaFig. 1 - 1 0. Gas pare Tagliacozzi (bookplate of Dr. J erome
P. Webster). (Cou rtesy Jerome P. Webster, M.D.)

* From G i l lies, H. D., and M i l l ard, D. R. : Pri nciples and

art of plastic su rge ry, Bosto n , I957, Littl e. B rown & Co.

Fig. 1 - 1 1. B renthurst Cl inic tapestry. (Cou rt esy Mr. Jack Pe n n .)

The principles and purpose of plastic surgey-past and present

ta ns, b u t as becom e the good p h ysicia n s and fol lowers
of the great H i p pocrates. For a l t h o u gh the original
bea u ty of the face i s , i n d eed , restored , this i s only acci
d e n ta l , and the end for w h ich the ph ysician is working
i s that the featu res should fu l i l l their o fices accordi n g
t o nat u re's d egree. *

Tagliacozzi was given to the use of lowery

phrases that characterizes much scholarly writing
of the sixteenth century. A more succinct delinea
tion of the purpose of plastic surgery was given by
a general surgeon of the twentieth century, Wil
liam Mayo.24 His statement of the purpose of plas
tic surgery is inscribed in a tapestry at the Brent
hurst Clinic in South Africa.23 This tapestry depicts
the history of plastic surgery beginning with the
ancient Egyptians who treated facial fractures and
the Indian castes who reconstructed noses from
forehead laps as described in the Cowasjee broad
side. The tapestry depicts Tagliacozzi, as well as
the modern plastic surgeon and his patient. Just
as Millard described Gillies' principles as being the
Ten Commandments of plastic surgery, so do the
words that Mayo used to describe the purpose of
plastic surgery represent a commandment in
themselves for the purpose of plastic surgery and
are an appropriate point for closing. Mayo said,
"It is the divine right of man to look human"
(Fig. 1- 1 1).
* From Tagliacozzi , G. : De cu rtor u m c h i r u rgia per i n si
tionem. Tra n s l ated in Gru d i , M . T. , and Webster, J . P. :
Life and Times of Gaspare Tagliacozz i , N e w York, 1 95 0 ,
H e rbert Reich ner, p. 3 3 1 .

REFERENCES

I . A n o n y m o u s : I n sti t u t Acade m i e des Sciences, R h i no

plastie , J . U n iv. H ebdomadai re 5 :4 1 7 , 1 83 1 .
2 . A n o n y m o u s : M S cata logue of Sir A s t l ey Cooper's
preparations, H u n terian M u se u m , Royal Coll ege
of S u rgeo n s , London.
3. A nonymou s : R h i noplastic operatio n , Med. C h i r.
Rev. 1 7 : 1 72 , 1 83 2 .
4 . Bailey, H . : Case of reu n ion o f t h e first phalanx o f
the m i d d l e i n ger com m u n icated i n a let ter to Dr.
W i l l iam B a l fo u r , Edin. Med. S u rg. J . 1 1 :3 1 7 , 1 8 1 5.
5. B a l fo u r , W . : Two cases, w i t h observations, demon
strative o f the powers o f natu re to reu nite parts
wh ich have bee n , by accident , totally separated
from the a n i mal system , E d i n . Med. S u rg. J. 1 0 :
42 1 , 1 8 1 4 .
6 . Bal fou r, W. : O n the first notice o f a re-u nion a fter
e n t i re separat ion of part s, London Med. Ph ys. J.
37:472, 1 8 1 7 .
7 . B l an d i n , P. : De l'autoplastie, Paris, I 836, U rtubie.

13

8. Carpu e , J . C. : A n acco u n t o f two su ccessfu l opera

tions for restori n g a lost nose w i t h the i n tegu ments
of the forehead i n the cases of two oficers of H i s
Majesty's army, i n w h i c h are i ncl uded historical and
physiological re marks on the n asal operation includ
ing descri ptions o f t h e I ndian and I talian methods,
London , 1 8 1 6 , Longma n , H u rst, Rees, Orme, and
B row n .
9. Carp u e , J . C. : Geschi c h te z w e i e r gel u n gen Faile wo
der Verlust der N ase, B e r li n , I 8 I 7, Realsch u l
buch h a n d l u ng.
1 0 . Darwi n , F. : Francis Galton 1 82 2- 1 9 1 1 , E u g. Rev.
6:9, 1 9 1 4.
I I . D u n h a m , T. : Method for obtai n i n g a skin fl ap from
the sca l p a n d a perm a n e n t b u ried vascu lar ped icle
for covering d efects of the face, Ann. Su rg. 1 7 : 6 7 7 ,
1 893.
1 2. D u play, S. , and Rec l u s , P. : Traite d e c h i r u rgie,
vol. 4 , Paris, I 89 I , G. Masson.
1 3. Fiorava n t i , L. : I I tesoro della v i ta h u mana, Venice,
I 5 7 0 , Sessa.
1 4. Fresh water, M . F. : More abo u t B. L. , M r. Lucas, and
M r. Carpue. Plast. Recon str. S u rg. 49 : 7 8 , 1 97 2 .
1 5. Freshwater, M . F. : George David Pollock a n d t h e
development o f s k i n graft i n g , M . D. thesis, Yale
U n iversity, N ew H aven , Con n . , I 972.
1 6. Fresh water, M . F. : Pre- Baronian t i ssue transfer,
Conn. Med. 40: 6 1 3 , 1 976.
I 7. G i ll ies, H. D. : Plastic s u rgery o f the face, London ,
1 920, Oxford U n iversity Press.
1 8. G i l l ies, H. D., and M i llard, D. R. : Pri nciples and
a rt of p lastic su rgery , Bosto n , 1 95 7 , Little, B rown
& Co.
1 9. Littler, J. W. : N e u rovasc u lar pedicle transfer of
t i ssue in reconstructive s u rgery of the han d , J. Bone
J o i n t S u rg. 3 84 : 9 1 5 , 1 956.
20. M i llard, D. R. : Plastic peregri nations, Plast. Re
constr. Su rg. 5 : 2 6 , I 950.
2 I . Monks, G. H . : Restoration of a lower eyelid by a new
method , Boston Med. S u rg. J. 1 39 : 3 8 5 , 1 898.
2 2 . Owen , R. : On the archetype and homologies of the
vertebrate skeleto n , London , 1 84 8 , J . Van Voorst.
23. Pen n , J . : B ren th u rst C l i n i c tapestry, B r. J . Plast.
S u rg. 2 0 : 1 04 , 1 96 7 .
2 4 . Pen n , J . : Personal com m u n ication , J u ly , I 970.
25. Reisinger, F. : Die Kerato p lasti k , Bayeri sche A n n .
1 : 2 0 7 , 1 82 4 .
26. Tagl iacozz i , G. : De c u rtor u m c h i r u rgia p e r insi
tionem. Translated i n G n u d i , M . T. , and Webster,
J. P. : Life and times o f Gaspare Tagliacozzi , New
York, I 950, H e rbert Reic h n er.
2 7 . Tubiana, R., a n d Du parc, J . : Operation pall iative
pour paralysie sensitive a I a m ai n , Mem. Acad.
Surg. 8 5 : 666, I 959.
28. Von E sser, J . F. S. : I sland flaps, N . Y. Med. J . 1 06 :
264 , 1 9 1 7 .
2 9 . Von Graefe, C. F. : R h i n o plast i k , Berli n , 1 8 1 8 ,
Realsch u lbuchhand l u n g.
3 0 . Wales, J . : Singu lar operatio n , Lo ndon, I 795 , Cribbs.
3 1 . Zeis, E. : H an d buch der pl astichen C h i r u rgie, Berli n ,
1 83 8 , G. Reim er.