Introduction

If you're like me and you are 30+ years old, you may have noticed that your once smooth facial skin is desperately trying to roleplay as the Grand Canyon. With creases, crevasses and grooves making themselves permanent residents of your forehead, you may have even thought about looking up a plastic surgeon. Plastic surgery is famous for skin tightening and smoothening, a deadly botulotoxin was popularized not for it's deadliness, but for relaxing facial muscles, thereby restricting movement of both muscles and attached skin, causing all those deep creases to disappear for a while, until another dose of the paralytic agent marketed as "Botox" is warranted. Yes, plastic surgery does focus on aesthetics and procedures aimed at improving one's looks, but the field is far more vast than skin-pulling and butt-lifting. In fact, plastic surgery as a specialty did not start with purely aesthetic procedures and today is certainly not represented by aesthetic surgery alone.

The term "Plastic" in plastic surgery does not originate from synthetic polymers we have polluted our world with, but comes from a Greek word "plastikos", which means to mold or give form. Molding, changing, giving new form is what ancient Indian scholar Sushruta, working near the modern-day city of Varanasi, described in ancient Sanskrit texts. In these writings from 600 B.C., a procedure that involves reconstructing the nose by cutting skin from either the cheek or forehead, rotating the skin over a leaf, and eventually suturing the skin into place was described.  This method became known as the “Indian Method of Rhinoplasty". This is one of the first reconstructive procedures ever described. 

Since then, the field of plastic and reconstructive surgery (PRS) would not actively grow until the late 19th, early 20th century. While there have been descriptions of reconstructive procedures to correct deformities and injuries by Romans, ancient Greeks, Arabs (notably Al-Zahrawi), and in the Middle Ages and Renaissance, most were poorly documented and did not have great outcomes, mainly due to the lack of anatomical knowledge. In fact, knowledge of anatomy and variable anatomical differences between humans is still at the forefront of any innovation in surgical technique. So if you are reading this and you are in medical school: sorry, anatomy is a must know. The history of plastic surgery is incredibly interesting, but is not the main topic of our discussion today. Today, I want to talk about how this field became so much more than it was 100 years ago: due to technological advancements, branches of PRS becoming standalone specialties, the dominating of PRS in other fields and in some cases due to nothing more than tradition. 

The victims of war and surgical innovation

For the most part, modern techniques used in PRS took root in the field army hospitals and were first performed by military surgeons, who were tasked with a varying complexity of wound closures, extremity reattachments, burn treatments and addressing other harrowing derivates of war.  There are many names that should be mentioned when discussing this era, including Sir Harold Gillies, Sir Robert Jones, Henry Pickerill, Hippolyte Morestin, Erich Lexer, Jaques Joseph, Otto Lanz, Johannes Esser, Vladimir Petrovich Filatov, Archibald McIndoe, Luke Voyno-Yasenetsky, Vincenz Czerny, Suzanne Noël and many others. These names are well remembered, but what is of utmost importance to remember are the soldiers and all other victims of war, their suffering and pain, their sacrifice that is often overshadowed by the books written about their treatment and the fascinating discoveries made from their pain. These patients deserve as much memory and respect, as do the surgeons, nurses, anesthesiologists and medics who treated them and other on the battlefields (Source 1, Source 2). 

William Vicarage was wounded at the Battle of Jutland on May 31st, 1916. He was just 20 years old when he sustained severe burns to his hands and upper body, his eyelids and lower lips were turned inside out, leaving him unable to close his eyes or open his mouth. He was the "epiphany patient" for Sir Harold Gillies, admitted for treatment in August 1916. On October 3, 1917, when treating William Vicarage, Sir Gillies released a large ‘masonic collar flap’ of skin from William’s chest and stitched it to the lower part of the face with connecting flaps of skin (the first pedicle flaps) which maintained a c blood supply to the large graft. As the flap was raised and sutured in place on William’s face, the long parallel edges of the connecting pedicle flaps of skin curled in toward each other under tension. It is noted that when observing this, Gillies began to stitch the long edges together to form tubes to the astonishment of those present in theatre. Tubing the pedicle flaps ensured better supply of blood and reduced the chance of infection to the raw underside of the flaps (Source 1, Source 2, Source 3).

 Henry Ralph Lumley, underwent one of the first tube pedicle flap reconstructions performed by  by Sir Harold Gillies, a multi-step surgical procedure to transfer healthy autologous tissue to a different region. The first stage of the procedure was performed on October 24th, 1917. On February 18th, 1918 he underwent the second stage of the procedure: surgical removal of the facial scar tissue and transpositioning of the flap onto the face. Due to the large graft size and Lumley's poor condition, the anterior thoracic skin flap was rejected and he died of heart failure on March 11th, 1918. Henry Lumley was a pilot and was one of the very first patients who underwent flap reconstruction. March 11th, 1918 was just short of Lumley’s 26th birthday and twenty months after his accident. His procedure commenced a few weeks before Walter Yeo, the first recorded and published patient to receive a successful autologous flap transfer for facial reconstruction. The lessons learned from the failure of Henry Ralph Lumley's surgery would go on to help thousands of people. But this failure that taught the world several foundational rules about flap transfer (that such flaps fail if they are too large, several smaller flaps are preferable when closing a large defect), cost Henry Lumley his life. His life should be remembered when thinking of plastic surgery today (Source 1, Source 2, Source 3).

Walter Ernest O'Neil Yeo received one of the first documented successful tube pedicle flap reconstructions of the face. He was wounded on May 31st, 1916, during the Battle of Jutland and sustained terrible facial injuries, including the loss of upper and lower eyelids. He was treated by Sir Harold Gillies, who treated him with a newly developed technique, a form of skin transplantation called a 'tubed pedicle' flap. The first stage of the surgery was done on November 12th, 1917 and the flap transfer was carried out on November 30th, 1917. Walter Yeo endured infection, several surgeries, pain, movement restrictions and other hardships until he was discharged on December 15th, 1921. To this day, tube flap multi-stage reconstructive procedures remain a viable method of major defect reconstruction. With advancements in technique, patient safety focus, knowledge of vascular anatomy, skin perforators and perfusion zones, preference lies with free or vascular pedicle flap transfer. Walter Yeo dedicated 5 years of his life to this knowledge and this field as a patient. He died in 1960 at the age of 70 in Plymouth.

Unnamed child, female, 6 years of age. There were many unnamed patients reported in the early days of plastic and reconstructive surgery. A case of a child that had severe burns to the head and neck stands out as one of the first cases of a complex procedure to drill holes in the skull in order to achieve granulation for further reconstruction. The surgeon who treated this girl, Davison T.C.,  wrote "the removal of slough left the bone bare for an area of approximately 4 by 6 inches. The wounds around the bare bone became healthy; granulations spread out, but for the lack of circulation, they extended only a short distance over the denuded area. The bone began to undergo necrosis and softened in spots, but at the same time granulations appeared through the two parietal foramina and, to a slight extent, through the suture line between the two parietal bones. This suggested that if there was enough foramina there would be enough granulation to cover the surface. Skin for flaps was not available, the skin of the neck having already been destroyed; Tiersch and pinch grafts would not grow on the dry and softening bone. So, instead, I drilled about fifty holes through the dry calvarium at the intersection of squares measuring 1cm, each way. The purpose of the drilling was to obtain a blood supply; so when blood was drawn the drilling stopped. In the softened areas, over the parietal eminences, the drill at times went through more quickly than expected, punctured the dura, and permitted the escape of cerebrospinal fluid." This procedure, for which the patient endured fever, several month of observation and reoperations, loss of blood, pain, resulted in success. The success was the appearance of granulations, which "grew rapidly, spread out, mushroom-like, over the denuded area, and where they met they fused, thus gradually, over a course of weeks, covering the whole area". The granulations were live tissue over dying bone and allowed for epithelium from wound edges to grow over the granulose tissue and for pinch skin grafts to close the remainder. This child was one of the first recorded patients to undergo such a complex and difficult to endure procedure, which had her hospitalized from December, 1915 to July, 1916. This procedure is used to this day (Source 1, Source 2), albeit more effective alternatives have since been developed. 

Unnamed patients of W. Likely Simpson. On July 4th, 1919, doctor Simpson from Memphis, Tennessee, published an article on "A method of closing perforations of the septum of the nose", where he introduced utilization of cartilage for reconstruction of the nasal septum. Numerous patients were feature in this work and even more served as a foundation for the surgical innovations he presented.

Originally, I intended to delve further into listing the names that contributed to PRS specialty, but found myself quoting more and more from Dr. Bamji's book "Faces from the Front". I discuss this book and Dr. Bamji further.

Remembrance

In my efforts to explore these topics deeper, I was astounded by the incredible work by Patrick Hartley and Andrew Bamji. They were kind enough to both agree to talk to me and answer my questions, and in time I will follow up with full length talks with both Patrick and Andrew. Meanwhile, I want to share what deeply resonated with me in their work that focused on the first patients of plastic surgery, the victims of war and in many ways on remembrance.

Patrick Hartley: the incredible artist whose silent works speak incredible volumes. I reached out to Patrick Hartley with a simple request to access some images on his webpage (http://paddyhartley.com/menu). While exploring his work, I felt a lot of different emotions: fear, sadness, dread, relief and even blissfulness. I wanted to learn more about him, and I still do. One of his exhibits focused on creating commemorative substrates that almost bring to life some of the first patients of Howard Gillies. This was the "Project Facade & The Gillies Archive". I will not go into detail about our further communication, as we have yet to meet and talk, but I felt a deep connection to this artist as a human being, because I felt like the feelings I want to express about the first patients that contributed to the specialty of plastic surgery today, he masterfully portrayed in palpable art. 

Andrew Bamji: the lifelong scholar, who dedicated an incredible amount of time and effort to preserving the memory of those forgotten by time. Andrew Bamji has put in an astounding amount of effort into creating the Gillies Archive - which is now being handed over to BAPRAS. His book "Faces from the Front" should be in every plastic surgeon's library. He has masterfully reviewed withering archived works and combined them into a unique book that evidences the patients, the soldiers, the faces from the front - all of whom contributed to the specialty of plastic and reconstructive surgery. Dr. Bamji agreed to talk to me about his experience in this field and we had a lovely chat that I will publish once I finish editing it. 

You: the plastic surgeon, resident or active contributor. Remembrance teaches respect - respect for the skills you apply in your work, respect for the patient and history of the field. The things we know and perform with relative ease in the 21st century derive from a long history of failures, pain and lost lives. Medical students and residents should be taught the history of modern procedures, so they can understand that the standards set forth today in patient safety, management and tactics are there for a reason. You can't ignore a follow-up, skip a surgical step to expedite a procedure or dismiss a poorly placed suture - 100 years ago that cost a patient their life. Rules on flap size, timing of surgery and technique exist for a reason. 

BMC Plastic and Reconstructive Surgery

The goal of our new PRS journal is to open our doors to the field that outgrew itself, branched off into sub-specialties and standalone topics. Our goal is to once again unify the vast plastic and reconstructive surgery field and welcome sound science publications that will define the next step in the growth of this modern, rapidly evolving and necessary field. We welcome your submissions!