Although the word plastic is derived from the Greek word plastikos, meaning to mold or give form, the true origins of the modern specialty of plastic and reconstructive surgery predate even this archaic linguistic root. Some historians trace the foundations of the specialty as far back as the early papyri of Egypt and the Sanskrit texts of ancient India. Within these early Hindu texts, possibly written more than 2600 years ago, lie descriptions of nose, ear, and lip reconstructions using techniques ranging from pedicle flaps to free autogenous skin grafts.
Although the first use of the word plastic to describe this type of reconstructive surgery was not coined until 1818 by Von Graefe in his Rhinoplastik, the specialty has been forged slowly since ancient times into its present-day structure. It has evolved into an extremely diverse specialty with a breadth and depth that blur its boundaries with other fields. Its sheer scope in modern times is truly a testament to the contributions of many individuals from varying backgrounds and medical specialties who have come together to form and refine it.
While sterile technique, anesthesia, antibiotics, and the accumulation of basic science knowledge all have reshaped this specialty over the years, the ultimate goals have remained the same: the restoration of normal form and function and the possibility of the enhancement of form to super normal proportions.
Egyptian physicians may be credited broadly as the earliest contributors to the modern specialty of reconstructive plastic surgery. The Edwin Smith Papyrus, the origins of which are dated at approximately 3000 BC, contains the first descriptions of the surgical management of facial trauma, including the treatment of mandibular and nasal fractures. Such descriptions are impressive for their age, for their basis on scientific principles, and for their departure from the superstitious attitudes of the time.
Many hundreds of years would pass before the true birth of reconstructive surgery occurred. Although the precise date is disputed by historians, the first recorded description of actual reconstructive plastic surgery may be traced back over 2600 years to the Sanskrit texts of ancient India. During this period such surgery was needed greatly, as acts of facial mutilation, especially of the nose, were perpetrated commonly in India and its surrounding territories by vicious bands of marauders as a method of visible and lasting humiliation.
The Hindu justice system also contributed to the need for reconstructive surgery by levying harsh penalties upon its subjects for various crimes, including amputation of the genitalia or nose of an unfaithful spouse. It appears reasonable that the nose, a symbol of dignity and respect in many societies throughout antiquity, should be among the first as well as a recurring subject in the history of plastic and reconstructive surgery.
In his Samhita, or encyclopedia, the Hindu author Sushruta first described both a reconstruction of the earlobe using skin from the cheek and a traditional method of reconstructing the nose, commonly referred to since as the Indian or Hindu method. This involved the use of a pedicle flap either from the forehead or the adjacent cheek as the tissue source for reconstruction. Whether this original Indian method used a pedicle cheek flap rather than a forehead flap, as commonly is reported by historians, remains unclear. However, translations of the Samhita from its original Sanskrit indicate that the cheek was probably the preferred source for the nasal reconstruction flap.
I now narrate the proper method of constructing a nose of one whose nose is mutilated. A careful physician having taken a plant leaf of the size of the nose of that person, and having cut adjoining cheek according to that measurement, and having scarified the nose tip should attach it to the nose tip and quickly join it with perfect sutures When the healing is complete and the parts united, remove the excess skin. If the nose is smaller than required, try to increase it; if it is in excess, trim it.
While early research originally dated Sushrutas work at approximately 600 BC, modern historians dispute this, placing its first writing anywhere from 400 BC to the first century AD. Whatever the true date, Sushruta unquestionably was an important early contributor of actual reconstructive technique to the specialty of plastic surgery.
The use of full-thickness free skin grafts also has been cited as an interesting and alternate method of nasal reconstruction used by Indian surgeons. This technique, along with the pedicle flap nasal reconstruction, was performed by the Koomas caste of tile and brick makers. It reportedly entailed the use of a free autogenous full-thickness skin graft harvested from the gluteal region and applied to the nasal defect. If accurate, such a technique predates the first officially successful autogenous skin graft, cited by Reverdin in 1869, by more than 2 millennia.
Whether full-thickness free skin grafting truly was practiced or even feasible in ancient India always has been in doubt. If this technique did exist, why is there no evidence that it was practiced throughout the ages and into recent history, as with the traditional Indian method using the cheek or forehead flap As reported by Haube and Koch in 1941, if it was actually carried out, it remains an achievement that the surgeons of today have not been able to equal.
Buenger reportedly performed a successful reproduction of this technique in 1821. No matter what the original technique, these early methods of nasal soft-tissue reconstruction appear even more incredible when considering that Indian surgeons likely had practiced them for many years, perhaps many generations, prior to their being described in the literature. Hellenistic, Roman, and Byzantine reconstructive efforts
Whether these Hindu methods of facial reconstruction spread immediately throughout the ancient world or largely remained the secret of their creators until later centuries, when more certain connections between Western and Indian civilization can be documented, is unclear. While the sharing of medical knowledge between Greek and Indian civilizations reportedly existed even earlier than Alexander the Greats expedition to India in the fourth century BC, the transfer of such reconstructive technique prior to the seventh century BC, although likely, has never been confirmed.
This remains an interesting question, considering that several Hellenistic and Roman physicians described the care and surgical correction of various facial defects in a manner similar to that of their Indian counterparts. Aulus Cornelius Celsus, considered by many to be the greatest Roman medical writer, included similar techniques to repair mutilated lips, ears, and noses in his classic medical text of the first century, Demedicina. Therefore
The royal Byzantine physician Oribasius, whose contributions to plastic surgery are found in his comprehensive medical encyclopedia entitled Synagogue Medicae, followed Celsus in the fourth century. Within this 70-volume text, which encompassed the broad sum of existing Roman and Hellenistic medical knowledge, Oribasius devoted two chapters to the reconstruction of facial defects. He demonstrated his understanding of basic reconstructive principles, including the importance of tensionless suture lines, the debridement of exposed bone to aid in the healing of overlying skin, and the use of flaps to avoid the distortion of facial features associated with primary closure.
Oribasius described in detail the use of bipedicle advancement flaps for skin defects around the area of the eyebrow, ala, cheek, nasal dorsum and tip, columella, and ear. To create a square defect around the original wound in the design of this closure, he instructed the removal of healthy surrounding tissue, a rather bold suggestion for his time. Also of great significance was his technique of undermining the tissues prior to wound closure. He warned of skin necrosis if the skin alone was undermined, and instead advocated the inclusion of subcutaneous tissue when undermining to maintain blood supply and avoid necrosis.
Oribasiuss techniques of alar and ear repair further demonstrated his thorough grasp of reconstructive knowledge. He understood the importance of cartilage on the underlying structure of the ear and nose and advocated removing a small amount of it when repairing defects to avoid buckling in the final result. His method of alar reconstruction used what may be the first superiorly based nasolabial flap, as described in this free English translation of the original Greek text, provided by Lascaratos and Cohen.
If we have a defect in the ala, we must create a flap adjacent to the nose extending the vertical lines of the square (defect) towards the medial canthus mediall, and the eyelid laterally. After undermining, we advance the flap towards the defect.
Oribasiuss establishment of such enduring principles of wound management and facial reconstruction was an important and lasting contribution to the specialty of reconstructive plastic surgery.
Decline of the Middle Ages
The practice of established methods of facial reconstruction continued into the early Middle Ages. For example, Emperor Justinian II is believed to have benefited from nasal reconstruction in the eighth century. Known as the Rhinometus, or the one with an amputated nose, Justinian II was overthrown and his nose mutilated so that his disfigured appearance would prohibit him from regaining the status of emperor.
These efforts were futile, as he subsequently returned to power, reportedly the recipient of a nasal reconstruction. Examination of his facial features on ancient marble statuary indeed has revealed the presence of a forehead scar and the suggested form of a reconstructed nose.
Despite continued use of established methods, the fall of Rome in the fifth century and the subsequent spread of barbarian tribes and Christianity throughout the Middle Ages brought an unfortunate halt in the advancement of reconstructive surgery. The atmosphere of the time was demonstrated in the 13th century when Pope Innocent III specifically prohibited surgical procedures. The practice of medicine had devolved into a purely ethereal experience, where contact with the patient was avoided and surgery was scorned.
Abu Al-Qasim Khalaf bin 'Abbas el-Zehrawi (940 - 1013 C.E) Albucasis
After fall of Roman in the fifth century and spread of barbarian tribes and Christianity in the Middle Ages there was a halt in the advancement of this specialty. In 13th century when Pope Innocent 111 specifically prohibited surgical procedures, the advances in surgery remained declined. During the ensuing dark ages in Europe most of the development of surgery occurred in the Arab School with Albucasis ( El-Zahrawis 950-1013 A.D ) in tenth century giving us the best description of advances in surgery.( Spink, M.S., and Lewis, G.L.: Albucasis on Surgery and Instruments. University of California Press, Berkeley, 1973) In relation to Plastic Surgery he not only described the management of nasal fracture but also reduction mammaplasty. El Zahrawis had a tremendous influence on Surgery in the West. The French surgeon Guy de Chauliac in his 'Great Surgery', completed in about 1363, quoted El Zahrawis's At-Tasif over 200 times. El Zahrawi was described by Pietro Argallata (died 1423) as "without doubt the Chief of al Surgeons".
Islamic conquest of India, the Indian method of reconstruction presumably passed to Arabic Culture, which in turn likely passed this knowledge to all Europe with the conquest and occupation of Sicily during 9th and 12th century. In 15th century, Turkish Islamic literature revealed Serafuddin describing the technique of eyelid & maxillofacial surgery. He also mentioned the surgical treatment of gynecomastia. He was one of the first to describe the management of specific fractures. The basic principles which he mentioned to correct ectropian and entropion remained in use today. His surgical management of gynecomastia may be considered as precursor of modern mammplasty though this was already mentioned by El- Zehrawis in 10th century.
Most physicians of the time considered the manual labor required for such surgical endeavors quite dishonorable and beneath their esteemed stature. While minor advancements occurred, as evidenced by the first description of a European operative repair for cleft lip found in the Leechbook of Bald in approximately 920 AD, the solid scientific foundations of early Hellenistic, Roman, and Byzantine medicine ultimately gave way to mysticism in the Middle Ages. The development of the barber surgeon commenced, and the art of surgery fell into further disrepute.
The Renaissance
The advent of the Renaissance in the 14th century brought a rebirth of science and medicine and an end to the stagnation that had befallen the world of surgery. Yet, while the Middle Ages truly yielded few significant surgical developments, the reconstructive principles and techniques of the early Indian, Hellenistic, and Roman pioneers had been kept alive, passed on from generation to generation, and more importantly, from one civilization to another. With the Islamic conquest of India in the 10th century, the Indian methods of facial reconstruction presumably were passed to the Arabic culture, which in turn likely bestowed this knowledge upon all of Europe with the invasion and occupation of Sicily during the 9th-12th centuries.
Interestingly, the rebirth of reconstructive surgery in the 15th century had both Eastern and Western origins. In his illustrated surgical treatise titled Imperial Surgery, the first illustrated surgical text in Turkish-Islamic literature, Serafeddin Sabuncuoglu described techniques of maxillofacial surgery and surgical treatment of eyelid disorders and gynecomastia. While his methods of treating facial fractures were in no way revolutionary, he was one of the first to describe treatment of a variety of distinct fractures. In addition, the basic principles underlying his methods to surgically correct entropion and ectropion remain in use today.
Perhaps the most interesting aspect of his work was his treatment of gynecomastia. Although evidence suggests that the surgical treatment of gynecomastia was practiced to a limited extent in ancient times, Sabuncuoglu offered what may be the first clear description of a surgical technique to remove glandular breast tissue for cosmetic purposes. His method may be considered a precursor of the modern reduction mammoplasty.
In 15th century Sicily, the famous Branca family also was contributing to the revival of reconstructive surgery. The elder Branca, a wound specialist, was responsible for re-introducing the Indian method of nose reconstruction around the year 1442. Some historians question whether Brancas technique was based on the Indian method or whether he developed the procedure independently.
Just as the techniques of facial reconstruction were kept guarded within the Koomas caste in ancient India, the Branca family also guarded its techniques. Therefore, it is apparent that surgeons of this age more closely resembled barber surgeons than medically educated physicians who would be more willing to disseminate medical knowledge. The technique was passed down only among family, and observers who might have pilfered the technique were not allowed to view the procedure.
Brancas son, Antonius, inherited this technique and made significant modifications, using instead a delayed skin flap from the arm as the primary source of tissue. It also was used to repair lip and ear defects. This Italian method, as it came to be known, somehow was transferred to other families, including the Sicilian surgical family known as the Boiani of Calabria. Professor Alexander Benedictus of Padua described the procedure performed by the Boiani family as follows:
A flap is detached from the arm and cut in the form of a nose to be applied to the stump of a nose. They detach the skin from the arm with a bistoury, scarifying the nose, and attach the arm to the head, in such a manner that the two wounds are applied to one another. When union is perfect, they cut off with admirable skill, as much skin off the arm as necessary to form a nose.
While the barber-surgeon certainly dominated the landscape of reconstructive surgery during this time, Leonardo Fioravanti, a physician trained at the University of Bologna, played a crucial role in disseminating knowledge and stimulating other academics to take a similar interest. Cleverly posing as a squeamish and uninformed observer, Fioravanti observed several nasal reconstructions performed by the Vianeos family and later published these accounts for all to read in Il tesoro della vita humana.
Although several less detailed descriptions of the Italian and Indian methods of nose reconstruction already had been written during this time, they were not nearly as well known as Fioravantis accounts. His descriptions may have been responsible for sparking Gasparo Tagliacozzi's interest in the subject of nasal reconstruction. Tagliacozzi often has been referred to incorrectly as the originator of the Italian method, yet his contributions to reconstructive plastic surgery are, nevertheless, significant.
Working in Bologna during the latter half of the 16th century, Tagliacozzi introduced the principles and use of distant pedicle flaps and carefully detailed the delayed arm flap of the Italian method. This effort by Tagliacozzi made the technique famous in Italy, although the rest of Europe did not appear to hold it in such high regard.
As seems typical of the cyclical nature of surgical history to this point, which is to fall periodically into the depths of superstition and scientific ignorance, reconstructive surgery in Europe near the end of the 16th century entered into another period of severe decline. Historically, this has been related most frequently with the "sympathetic theory," a commonly held fallacy at the time that stated that tissues transplanted from one individual would survive in the recipient only as long as the donor remained alive; death of the donor was believed to mean certain death of the donor tissues (eg, loss of a nose if the donor of the nose died).
Understanding why such ideas were discussed is difficult, since little evidence exists that reconstructive techniques of the time even used xenografts. Nevertheless, the sympathetic theory was a frequent subject of satirists, including Voltaire, and doubtlessly served to deepen the already present misconceptions surrounding reconstructive surgery. The pervasive effect of such misconceptions inevitably contributed to the dearth of interest in the subject for the next 2 centuries.
Not until the end of the 18th century did reconstructive surgery begin to resurface in Europe, ultimately providing the foundation of the modern era of reconstructive plastic surgery. Choparts 1791 reconstruction of a lip using a flap from the neck was one of the first contributions to this rebirth. The most often-cited impetus to this new age of reconstructive surgery was a simple letter published in London in October of 1794 on page 891 of the Gentlemans Magazine by a British surgeon named Lucas.
In this now-famous account, Lucas described an operative procedure that was used to reconstruct the nose of a British bullock driver, Cowasjee, whose nose was mutilated by the enemy as punishment for transporting supplies for the British East Indian forces. Performed in India by a man of the brickmaker caste, the procedure involved a forehead flap and was observed by two British surgeons who publicized the event locally.
As is true throughout much of the history of medicine, the value of a single contribution is gauged both by its intrinsic ability to bring progress to the field and by the sum of the subsequent contributions that it stimulates. In the case of Lucas letter, the revival of interest in reconstructive surgery was indeed tremendously important to the specialty.
Lucas's account was read by Joseph Carpue, a British surgeon at York Hospital in Chelsea, England, who reasoned, rather presumptuously, that if such a procedure could be performed in India by brickmakers, surgeons in Britain certainly could achieve it. Fortunately, Carpue was not incorrect in this assumption. After practicing the procedure several times on cadavers, he performed the operation in 1814 on a British military officer who had lost his nose to the toxic effects of mercury treatments, and on another officer whose nose was mutilated by a sword.
While reports at the time indicated that such nasal reconstructions in India took more than 1.5 hours, Carpue reportedly performed the entire procedure in 15 minutes (6 minutes for flap dissection and 9 minutes for homeostasis and closure), without the benefit of anesthesia. The dressing was removed on the third day, and the delayed pedicle eventually was cut to complete the successful operation. Carpue published the account of these successful operations in Restoration of a Lost Nose in 1816, and the Indian rhinoplasty again was revitalized in Europe.
Two years later in 1818, the German surgeon Carl Von Graefe, considered by many at the time to be the finest surgeon in Europe, published his major work entitled Rhinoplastik. While use of the term "plastic" to describe reconstructive surgery was popularized 20 years later by Zeis in his book Handbuch der plastischen Chirurgie, Von Graefe was the first to put it in print in 1818. In this well-illustrated text, Von Graefe cited 55 previously written accounts on the subject of rhinoplasty and described successful operations using the Indian and Italian methods, as well as a newly introduced German method.
For this new technique, Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap. His innovations were not limited merely to the realm of rhinoplasty. He also made numerous contributions to other aspects of plastic reconstructive surgery, including original techniques of blepharoplasty and palatoplasty. For these contributions, he is widely considered to be one of the fathers of modern plastic surgery.
Dieffenbach, who succeeded Von Graefe in Berlin, wrote a comprehensive text on rhinoplasty in 1845, entitled Operative Chirurgie. In this landmark text, he presented the subject in a manner that made it widely accessible and feasible for many surgeons of the time. He also introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose, and was one of the first surgeons to make reconstructive rhinoplasty more tolerable through anesthesia.
Others following these men improved upon their contributions and served to widen the scope of plastic and reconstructive surgery. While Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunken noses in 1892, James Israel, a urologic surgeon from Germany, and George Monks of the United States, in 1896 and 1989, respectively, each described the successful use of heterogeneous free-bone grafting to reconstruct saddle nose defects.
Aesthetic Influence
As the foundation of the modern specialty formed, important changes were taking place that affected the entire nature of the budding field. With the overall risks of surgery decreased through anesthesia and the development of sterile technique by Lister and others, the concept of performing surgery for reasons other than the reconstruction of damaged or altered anatomy was at last permitted to exist.
John Roe, an American otorhinolaryngologist, is credited as the first to develop an aesthetic approach to rhinoplasty, a significant step in the formation of aesthetically based surgery as a more distinct aspect of the specialty. This was facilitated, of course, by his introduction of the endonasal approach to rhinoplasty, a technique reportedly introduced earlier by Dieffenbach, although this was undocumented.
In 1891, Roe presented an example of his work, a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. He achieved this through an internal incision placed between the nasal bone and upper lateral cartilage. Roe was not alone in his beliefs regarding aesthetics. In Germany in the latter half of the 1890s, Vincent Czerny was performing rhinoplasty and was attuned to the concept of aesthetic surgery, promulgating the idea that aesthetic ends alone were enough to warrant surgical intervention.
Jacques Joseph, the German orthopaedic-trained surgeon, published his first account of reduction rhinoplasty in 1898. Although Roe and Weir preceded his efforts by several years, Joseph is regarded by most as the father of modern rhinoplasty. His analysis, classification, and repair techniques for the various types of nasal deformities make this title difficult to dispute.
His seminal work, Nasenplastik und Sonstige Gesichtsplastik, published in 1928, was one of the most comprehensive and innovative texts ever written on the subject. He also invented a number of surgical instruments related to rhinoplasty, many of which remain in use today. Together, these men provided the foundation of aesthetic intervention as a valid and justifiable aspect of reconstructive plastic surgery.
Interestingly, an important issue in modern plastic surgery was uncovered rather early in the history of aesthetic rhinoplasty, defying a commonly held perception that the problem is a more recent phenomenon. Weir was one of the first to identify this unfortunate byproduct of the budding field, a pathologic surgery-seeking behavior that he referred to as rhinomania. While such pathologic behavior certainly exists outside the confines of reconstructive surgery, it nevertheless persists as a particularly important problem for this speciality
While the development of nasal reconstruction occupied a large portion of the efforts of plastic surgery, the broad scope of the field today would be unimaginable without the contributions of those whose interests extended into areas other than rhinoplasty. Skin grafting, maxillofacial surgery, cheiloplasty, palatoplasty, and burn treatment were significant areas of development during the last several centuries.
Cleft Lip Repair
Cleft lip repair, which had been practiced in several forms since the fourth century of the Chin dynasty, enjoyed great advancement during the last 4 centuries. Earlier techniques involved simply trimming the edges of the defect and stitching them together, but in the 16th century, Franco and Pare developed a 2-stage approach to repair, first freshening the edges with sharp instruments or cautery and then performing a delayed approximation several days later with a harelip needle. During the same period, Tagliacozzi introduced the use of full-thickness sutures as an improvement to simple pinning.
In 1693, James Cooke, in his early textbook of surgery, described his techniques for the successful repair of unilateral and bilateral cleft lip. Despite superstitiously attesting that such birth deformities were usually causd by some Frights and strong Fancies, his accounts contained reasonable and scientific methods of repair. Cooke warned that cleft lip repair was more dangerous to perform on adults than on children and that prior to operating, the surgeon should consider what to do, lest you make it worse than it was. Other pragmatic advice included depriving the patient of sleep prior to surgery for 10 to 12 hours[so] that it may Rose contributed important technical and conceptual developments in cleft lip repair in the latter half of the 19th century. He advocated a bilayer closure of muscle and skin and recognized the importance of undermining the ala to achieve proper shaping of the nostril. His greatest contribution, though, was the introduction in 1891 of symmetrically curved incisions to achieve vertical lengthening of the upper lip upon apposition, a result that could not be achieved using previous techniques.
Hagedorn developed the quadrilateral flap for cleft repair in 1884, but this flap was not popularized until 1945 by LeMesurier. This flap achieved symmetry by partially recreating Cupids bow, but left the patient with a midline lip scar and undercorrection of the deformed nostril. The Tennison Z-plasty, first reported in 1952 and improved upon by Randall in 1959, preserved Cupids bow and left a less noticeable scar, but the technique partially destroyed the philtrum and created a transverse scar. The rotation-advancement design advocated by Millard in 1957 was one of the last major advances in this area, effectively recreating the philtrum and Cupids bow while hiding the incision lines at the base of the columella and ala and in the philtral edge. be disposed to sleep presently after.
Cleft Plate Repair
In contrast to cleft lip repair, developments in the repair of the cleft palate were relatively scant prior to general anesthesia and were limited to repair of the soft palate. The first successful repair of the velum was performed in 1764 by LeMonnier, a French dentist. In 1816, Von Graefe performed the first soft palate repair by applying an inflammatory agent to the edges prior to primary closure. For clefts of the hard palate, surgeons of the preanesthetic age prescribed the use of metallic or enamel prosthetic devices instead of repair.
Dieffenbach changed this mode of thinking in 1826 with the introduction of bilateral relaxing incisions and mucosal flap elevation to provide more tissue for hard palate closure. He vastly improved upon his technique in 1845 with the inclusion of vascularized periosteum into full-thickness mucoperiosteal flaps. This strengthened the integrity of the repair and greatly improved postoperative healing. Von Langenbeck built on the efforts of Dieffenbach by incorporating sections of the levator and palatopharyngeus muscles into his repair and creating a single-stage soft and hard palate repair.
In the 20th century, contributions from Dorrance and Wardill included 2-staged repairs, which attempted to achieve velopharyngeal competence through palatal lengthening for optimum speech development. They used bilateral V-Y advancement flaps to achieve lengthening. In 1987, Furlow introduced his bilayer double reversing Z-plasty technique of palate closure, which currently is in use. Bone grafting, an adjunct to cleft palate repair, first was performed in 1908 by Lexer and remains commonly in use.
Advent of Skin Grafting
Like many other aspects of plastic surgery, the idea and practice of skin grafting appears to have originated with ancient civilizations. The ancient Hindus reportedly used free skin grafts more than 2500 years ago as a source of tissue in their alternate method of nasal and facial reconstruction. Yet some doubt exists as to whether such a method was feasible in ancient times. Regardless, in 1570 Fioravanti was the first to report a successful skin autograft as recorded in the following account:
A certain gentleman, a Spaniard, that was called il signor Andreas Gutiero struggled with a soldier who cut off his nose and there it fell down in the sandand I who had it in my hand all full of sand urinated on it and having washed it with urinedressed itand bound it up and so left it to remain eight or ten days.
Modern interest in skin grafting began at the end of the 18th century, with Barionios skin grafting experiments in sheep, which he included in his text entitled On Grafting in Animals. Barionio successfully performed large free autogenous skin transplants to varying sites on the sheep. Astley Cooper is credited with performing the first successful human skin graft in 1817, using a full-thickness skin graft from an amputated thumb to cover the remaining stump.
Because many of the prominent leaders in the specialty were unsuccessful in their attempts at free skin grafting during the 19th century, perhaps from their preoccupation with rhinoplasty, the clinical importance of grafting was not realized until 1869. In this year, Reverdin, encouraged by his mentor Guyon, reported to the Imperial Society of Surgery of Paris the use of small, 2- to 3-mm epidermic, or split-thickness, grafts to speed the healing of granulating wounds.
Ollier, carefully studying the work of Reverdin, emphasized the importance of the dermal component of such grafts. He subsequently changed the name to skin graft. In 1872, he performed the first successful full-thickness autograft to treat ectropion. Le Fort and Lawson also used such grafts for the same disorder.
Wolfe's contribution to the advancement of skin grafting was his recognition that immediate grafting was possible over a fresh surgical wound. An ophthalmologist by training, Wolfe was given joint credit with Krause, a primary promoter of the full-thickness graft, for bringing the full-thickness skin graft into clinical use. In 1929, Vilray Blair and Barrett Brown developed improved techniques of split-thickness skin grafting, allowing the use of varying dermal thicknesses as appropriate for the situation, resulting in less shrinkage and contracture.
Various attempts were made to develop a mechanical device to facilitate the harvesting of skin grafts. One such implement was the calibrated knife, a primitive mechanical skin harvesting device developed in 1920 by Finochietto in Argentina. Blair developed another such skin grafting knife combined with a suction apparatus for removing the graft.
Perhaps one of the greatest advances in skin grafting, and, indeed, in all of plastic surgery, was the development of the dermatome. Padgett, a surgeon, and Hood, a mechanical engineer, developed the dermatome jointly in 1939. With its ability to provide the surgeon with quick, accurate, and uniform split-thickness skin grafts, the dermatome revolutionized the treatment of open wounds and burns, and remains one of the most important tools of the plastic surgeon.
While the unprecedented developments in reconstructive and aesthetic surgical technique during the 19th century propelled the components of the field toward coalescence, plastic and reconstructive surgery as a distinct and respected entity did not yet exist. At the turn of the 20th century, few reputable surgeons devoted their practice exclusively to reconstructive or aesthetic surgery. Such procedures were not considered vital or necessary by academic medicine at the time, and were performed by a limited number of surgeons of varying specialties only as an adjunct to their normal practice. The perception of plastic surgery as an illegitimate endeavor, unworthy of the lifesaving abilities of abdominal surgeons, was commonly held in the world of academic surgery. At the end of the 19th century, this negative attitude toward plastic surgery was influenced further by a proliferation of commercialized cosmetic plastic surgery practices, which commonly were run by surgeons of questionable ethics and skill. The rampant advertising campaigns associated with these practices compounded academia's unfavorable impression of plastic surgery and made most respected surgeons avoid the practice of plastic surgery altogether. Thus, plastic surgery entered the 20th century disorganized, fragmented, and without a true identity, its great advances tainted and its legitimacy as a distinct practice seemingly inconceivable.
World War I
The modern specialty of plastic surgery owes much to a group of distinguished surgeons whose efforts in the first half of the twentieth century, especially during the World Wars, advanced and unified the specialty and instilled it with the academic integrity that it possesses today. The first of these remarkable men was Vilray Papin Blair. In 1909, Blair, an American surgeon from St Louis, published groundbreaking photographs of his efforts in reconstructive mandibular surgery in the Journal of the American Medical Association.
Most notable were his attempts to correct mandibular prognathism. In 1912, he published a book entitled Surgery and Diseases of the Mouth and Jaw, which contained more photographic documentation of his work in this area. These publications were regarded highly and helped to both initiate the interest of other surgeons and to improve the publics perception of plastic surgery throughout the world.
Among his other achievements, Blair, with the assistance of Barrett Brown, developed advanced techniques of split thickness skin grafting in 1929, using a thicker dermal component than previously utilized and with greater success. Blair also holds the honor of being appointed chief of the first separate and distinct plastic surgical inpatient service in the United States, established at Barnes Hospital and Washington University.
One of Blair's greatest achievements was his contribution to the development of an effective military plastic surgical infrastructure during WWI. This allowed the military medical system to adequately deal with the large volume of reconstructive cases produced by the war. When the United States entered the conflict in 1917, the Surgeon General established several sections under the division of surgery, including ophthalmology, otolaryngology, and head and neck surgery.
For his accomplishments, Blair was chosen by the Surgeon General to lead the section of head and neck surgery. Boldly, Blair persuaded the Surgeon General to change his title from Chief of Head and Neck Surgery to Chief of Plastic Surgery. This was indeed a symbolic leap in respectability for the field.
During the war, the high volume of injuries accelerated advancement in most reconstructive areas of the specialty. This was particularly true with regard to maxillofacial surgery, since the nature of trench warfare supplied surgeons with an inordinate amount of head trauma.
With Robert H Ivy, originally a dental surgeon from Philadelphia, serving as his assistant, Blair established a unique system of military plastic surgery teams consisting of 15 general surgeons and 15 dental surgeons who worked together in specialized plastic surgery centers to repair and reconstruct the deluge of head and neck injuries during the war. Medical officers from numerous Allied countries underwent intensive surgical and dental training courses at these newly established reconstructive treatment centers in the United States, United Kingdom, and France. Playing a prominent role in wartime plastic surgery training in France was Morestin, a native of Martinique, who administered the French Army's plastic surgery treatment center at the Val-de-Grace Military Hospital in Paris. Among
his many credits, Morestin advanced the old idea that wide skin and subcutaneous tissue undermining was advantageous in wound closure and could be achieved without skin necrosis. In addition to his work with refining the Z-plasty for the correction of linear contractures and with cartilage grafting, he also developed the concept of using multiple partial excisions for the treatment of large lesions.
Although Morestin died prematurely of tuberculosis at 49 years old, his legacy endured in those whom he had inspired. One such surgeon was a British-trained otolaryngologist from New Zealand named Harold Delf Gillies. Gillies, who served in the British Army at a hospital in Rouen, France, was captivated by Morestins work and was compelled to emulate it. Early in the war, Gillies was chosen by Sir Arbuthnot Lane, head of plastic surgery at the Cambridge Military Hospital and one of the founders of the Queen Marys Hospital in Sidcup, Kent, to run the reconstructive treatment center at the Queens Hospital.
Gillies, and this center which he administered, played a significant role in the education of plastic surgeons from around the world. Ferris Smith, a prominent plastic surgeon from the United States, as well as Waldron and Risdon from Canada, were among the many who trained at this facility. For his heroic efforts, Gillies was later knighted by the Queen of England.
A number of technical advances in plastic surgery were achieved during the First World War. These included the extensive refinement of the use of flaps. By the end of the conflict, Filatov had published the design of the tube flap, and Blair had initiated work on the delayed transfer of long pedicle flaps. Free cartilage grafts and pedicle flaps also were used in nasal reconstructions. Bipedicled scalp and brow flaps were used to reconstruct the lip. The use of neck flaps to correct intraoral defects also was advanced.
The work of reconstructive surgeons during WWI captured the attention and admiration of the public and academia alike. Prior to the war, the use of crude facial masks to hide the disfigurements of wartime head and neck injuries was, essentially, the only option for those wishing to avoid the stares of society. Such ill-appearing devices were made nearly obsolete through the sheer efforts of plastic surgeons during the war. Lives were regained, hopes were restored, and miracles were apparently occurring at the hands of reconstructive surgeons.
Such miracles were achieved through a combination of the accelerated surgical learning curves inherent to all wartime medicine and the focused efforts of leading plastic surgeons. In essence, the war provided the stage by which surgeons could first begin to define the specialty's realm and demonstrate its abilities to the world. Creation of an organizational framework of plastic surgery triage and treatment, Allied reconstructive training centers, and the successful team approach to maxillofacial surgery made further possible the Herculean endeavors of early modern plastic surgeons during the war and advanced the specialty immeasurably.
The Interwar Period
The significant advances made throughout WWI were made apparent in the flurry of academic activity that began shortly after the war closed. Gillies documented his wartime experiences in his publication, Plastic Surgery of the Face in 1920. Blair too published his experiences in a paper titled Reconstructive Surgery of the Face. In 1919, John Staige Davis published the first American plastic surgery textbook titled Plastic Surgery - Its Principles and Practice. This widely read and highly influential book became a classic text of the field.
In 1928, Ferris Smith, an otorhinolaryngologist by training, explored the use of local facial flaps in his work, Reconstructive Surgery. Also during this year, Joseph published his seminal work on rhinoplasty titled Nasenplastik und Sonstige Gesichtsplastik. In addition to his writings, Joseph taught popular international courses on rhinoplasty that were attended by many prominent American plastic surgeons. Jacques Maliniac, a Polish immigrant who served as a military plastic surgeon in the Russian Army during the war, helped to establish the first division of plastic surgery at a public hospital in the United States at New Yorks City Hospital.
The 1920s and 1930s also saw the formation of numerous professional and academic societies pertaining to the field. In 1921, the American Association of Oral and Plastic Surgeons, the precursor to the American Association of Plastic Surgeons, was formed. In 1937, the American Board of Plastic Surgery was established, thus creating a standard of excellence for the field. In Philadelphia, Ivy started one of the first maxillofacial surgery residencies in this country. At Johns Hopkins, Davis is credited with establishing the first formal training program and fellowship in plastic surgery in 1924.
Acceptance of plastic surgery in the realm of academia was no more apparent than when the Department of Surgery at Johns Hopkins University, long opposed to Davis's dream of plastic surgery as a distinct specialty, appointed him as the first Professor of Plastic Surgery in the country. Of note, Halsted himself was one of the primary opponents to this recognition of plastic surgery as a separate entity.
World War II
Most historians agree that the defining moment for international reconstructive plastic surgery did not arrive fully until WWII. While plastic surgery flourished in the United States during the interwar period, its success was not as apparent in Europe and other parts of the world. Britain, for example, had only 4 dedicated plastic surgeons at the start of WWII (Gillies, Kilner, Mowlem, Mcindoe), compared with approximately 60 in the United States.
However, WWII forged a true international growth of the specialty. By the end of the war, the number of plastic surgeons in Britain had grown to 25. In the United States, this number had reached 150. In addition, only 20 medical schools with divisions of plastic surgery existed in the United States prior to the war. By the early postwar period, nearly 70 divisions of plastic surgery had been founded.
Several medical advances made during the interwar period enabled the extensive growth of the specialty during WWII. Improvements in anesthesia, more use of plasma for resuscitation, and the use of sulfonamides and penicillin to control wound infections contributed greatly to the decrease in mortality and morbidity of plastic surgical procedures during WWII. In some military plastic surgery centers, the mortality rate was zero.
In light of this improved control of infection, early closure of all facial wounds was now advocated, thereby substantially decreasing the disfigurement of healing by secondary intention. The addition of the dermatome to the armamentarium of the plastic surgeon in 1939 by Padgett and Hood also advanced the management of burns and open wounds tremendously.
The improved speed, precision, and ease of graft harvesting offered by this innovation made skin grafting easily accessible to all, thus permitting the widespread early coverage of burns and wounds that might otherwise have resulted in limb loss or severe facial deformity if left to heal secondarily. Limb amputation was used less extensively in WWII than in prior conflicts. Also among the important advances made in WWII was the use of cancellous iliac bone for reconstruction of the face and the widespread use of cross-leg flaps, tubed pedicles, and abdominal flaps for soft-tissue defects of the extremities.
As in WWI, the military plastic surgery treatment and training centers established during WWII played a significant role in the advancement of plastic surgical technique and in the training of the next generation of plastic surgeons. By the end of the war, more than 20 such facilities were established close to the fighting in Europe to manage mild-to-moderate injuries, and 9 centers were created within the United States to handle more complex reconstructions requiring longer recovery. J Barrett Brown was responsible for heading the US Army plastic surgery program in Europe.
Separate centers devoted to hand surgery also were created during WWII. Led by Sterling Bunnell, these centers were based on US soil and were staffed by both plastic and orthopaedic surgeons. Bunnell, a general surgeon by training from San Francisco, successfully incorporated aspects of general, orthopaedic, and plastic surgery into the treatment of hand injuries. His important text, Surgery of the Hand, published in 1944, detailed his comprehensive management of the injured hand.
Bunnell trained a number of surgeons throughout WWII, including J William Littler, a plastic surgeon who, in turn, trained countless other plastic surgeons in the art of hand surgery during the war. The efforts of Bunnell and Littler provided the United States with a new wealth of plastic hand surgeons after the war and established hand surgery as an integral element of plastic surgery.
The latter half of the 20th century saw tremendous growth in the specialty of plastic and reconstructive surgery. Currently, more than 5000 board-certified plastic surgeons perform more than 1.2 million reconstructive procedures and more than 1 million cosmetic procedures each year in the United States alone. Although the most common plastic surgery procedure performed today remains soft tissue tumor excision, with more than 521,000 such procedures performed in 1999, both reconstructive and cosmetic surgery have developed considerably over the past half century, and many new procedures and techniques fill the landscape of the specialty.
Re-Constructive Surgery
In the realm of reconstructive surgery, perhaps one of the most significant advancements has been the birth and maturation of microsurgery. Made feasible through the development of micro instruments, fine suture material, and the binocular operating microscope by the Carl-Zeiss Company in the mid-1950s, microsurgery revolutionized the field of plastic and reconstructive surgery. No longer were plastic surgeons limited to local pedicled flaps in their reconstructive efforts or forced to acquiesce in the face of an amputated limb or digit.
Microsurgery spawned a vast array of free flap techniques, and made neurovascular reattachment of severed extremities a reality. The first free skin flap transplant in an animal model was described by Krizek in 1965 using a superior epigastric-based axial abdominal free flap on a dog. In 1972, the first such free skin flap transplant in a human, a temporal free flap, was performed in Japan by Harii and Ohmori. Susumi Tamai reportedly performed the first replantation of a completely severed digit in Japan in 1965.
Harry J Buncke is regarded by most as the father of microsurgery. Buncke began his pioneering work in experimental replantation during the late 1950s and 1960s. After completing his training in skin flap surgery, he perfected his skills while experimenting with the replantation of rabbit ears and simian digits using the operating microscope and meticulous technique. In 1964 he reported the first successful replantation of a rabbit ear. Five years later, in 1969, he and Donald McLean performed the first successful microvascular tissue transplant, repairing a defect of the scalp with a free autologous transfer of omentum. Among his many credits, Buncke helped to establish microsurgical centers at a number of prominent institutions and trained a multitude of microsurgeons throughout his career.
Cosmetic Surgery
With more than a 175% growth rate in the 1990s alone, cosmetic surgery has indeed flourished. Currently, the most common cosmetic procedure performed by plastic surgeons is lipoplasty or liposuction. More than 230,000 such procedures are now performed by board-certified plastic surgeons each year in the United States. While the idea of using a blunt hollow cannula attached to suction to remove fat was initially described in the mid-1970s by two Italian dermatologic surgeons, Arpad and Giorgio Fischer, a combination of plastic, dermatologic, and head and neck surgeons helped to popularize this procedure in the United States in the late 1970s and 1980s.
The first American instructional course in lipoplasty was taught in 1982 by Dolsky and Newman, a plastic surgeon and otolaryngologist, respectively. In 1987, dermatologist Jeffrey Klein revolutionized lipoplasty with the introduction of tumescent anesthesia, which allowed for a significantly greater volume of fat removal, while at the same time decreasing bloodloss considerably.
Breast augmentation now ranks second only to lipoplasty as the most common cosmetic procedure performed by plastic surgeons in the United States. Nearly 170,000 such procedures were performed in 1999, representing a 413% increase since 1992. Essentially, 3 different means of breast augmentation have been attempted, with varying success, in the modern era of plastic surgery: autogenous tissue, injectable synthetic materials, and implantable prosthetic devices.
The earliest such attempt in modern times was the use of autogenous tissue, specifically adipose tissue, by Czerny in 1895, when he transplanted a lipoma from the back of a patient to her breast to correct an asymmetry. Many subsequent attempts to use autogenous tissue were made, ranging from the use of pure en bloc fat transfers from the buttocks or abdomen to dermal-fat-fascial transplants. However, these techniques met with limited success, mainly because of the unpredictability of graft resorption and its associated asymmetry.
While in recent years the success of myocutaneous autogenous augmentation, such as the transverse rectus abdominus muscle (TRAM) and latissimus dorsi flaps, has led to a revolution in postmastectomy breast reconstruction, the magnitude of such procedures precludes their use cosmetically.
The use of injectable synthetic materials to augment the breast first began at the end of the 18th century. Gersuny first proposed the injection of paraffin in 1899and he was shortly followed by others who substituted a variety of substances, including beeswax and vegetable oil, as the injectable material of choice. The practice of such direct injection was ultimately deemed harmful to patients and was prohibited from further use in the 1960s.
The last of the 3 methods of augmentation, implantable prosthetic devices, certainly have been the most successful. The first prosthetic devices were made of ivory or glass, but these materials were abandoned because of the highly unnatural appearance that they produced. Focus then shifted to spongelike materials, such as Ivalon, which could be fabricated to create a more natural appearance of the breast. However, use of sponge-type implants eventually was abandoned because of the late effects of shrinkage, hardening, and distortion caused by excessive scarring into the material.
The evolution of modern silicone-based implants began in 1963, when Cronin and Gerow introduced a silicone implant filled with silicone gel, with both the outer shell and inner gel material composed of silicone. The infamous litigation surrounding the safety of the inner silicone gel has led to the widespread use of inflatable saline-filled silicone implants. These inflatable implants have the advantage of being collapsible for insertion, thereby allowing their placement through a smaller surgical incision. The fact that they are filled only with saline also has helped to decrease health concerns regarding silicone-based implants Plastic surgery has enjoyed a long and storied history throughout the ages. It has been forged slowly over time through the contributions of many diverse civilizations and individuals. From otorhinolaryngologists, to dentists, to urologists, to orthopaedists, to modern plastic surgeons, the diversity of contributors has been incredible and has enabled its evolution into such a broad specialty. The relationship between plastic surgery and warfare throughout the ages has surely been symbiotic. With the largest number of facial injuries and burns produced in the history of war, World Wars I and II demonstrated the ability of plastic surgery to reconstruct the human form in a manner unlike anything previously seen.
During the last 50 years, the specialty has grown considerably. Innovations such as microsurgery have greatly widened the scope of reconstructive surgery, while extensive refinements in cosmetic surgery have enabled this aspect of the field to flourish. Although it has taken many centuries for plastic surgery to achieve its modern identity and place within the realm of medicine, the restoration of normal human form and function always has remained its most humane and admirable goal. These efforts throughout history indeed speak highly of those who have devoted their work to the advancement of the field and to the betterment of humankind.
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