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An Evidence-Based and Historical Review of War Surgery of the Face and Jaws

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An Evidence-Based and Historical Review of War Surgery of the Face and Jaws AN EVIDENCE-BASED AND HISTORICAL REVIEW OF WAR SURGERY OF THE FACE AND JAWS Darryl Chan Tong 2013 Supervisors Professor Robert Love Professor Tom Brooking i DECLARATION CONCERNING THESIS Author's full name and year of birth: Darryl Chan Tong 1968 Title of Dissertation: AN EVIDENCE-BASED AND HISTORICAL REVIEW OF WAR SURGERY OF THE FACE AND JAWS Degree sought: Doctor of Philosophy Permanent Address: 349 York Place, Dunedin, New Zealand I agree that this thesis may be consulted for research and study purposes and that reasonable quotation may be made from it, provided that proper acknowledgement of its use is made. I consent to this thesis being copied in part or in whole for i) the Department of Oral Diagnostic and Surgical Sciences Library ii) an individual at the discretion of the Library Services of the University of Otago Signature: Date: Note: This is the standard Library Declaration Form used by the University of Otago for all theses. The conditions set out on the form may be altered only in the most exceptional circumstances. Any restriction on access to a thesis may be permitted only with the approval of : (i) the appropriate Assistant Vice-Chancellor in the case of a Master’s thesis; (ii) the Deputy Vice-Chancellor (Research and International), in consultation with the appropriate Pro-Vice-Chancellor, in the case of a PhD thesis and after consultation with the Director of the University Consulting Group where appropriate. The form is designed to protect the work of the candidate, by requiring proper acknowledgement of any quotations from it. At the same time the declaration preserves the University's philosophy that the purpose of research is to seek the truth and to extend the frontiers of knowledge and that the results of such research which have been written up in thesis form should be made available to others for scrutiny. The normal protection of copyright law applies to theses. ii ABSTRACT War surgery of the face and jaws is a fascinating and complex area of surgery and medicine with a relatively short history of formal development as a specialty despite surgical procedures being performed on this area of the body over the centuries. It was not until the mid-nineteenth century when surgery was evolving into a science rather than a trade, that literature was being published on aspects of face and jaw surgery as well as some of the innovative appliances or techniques. The First World War was the birth of the specialties of plastic and maxillofacial surgery and provided abundant clinical material for the surgical techniques and innovations that would subsequently evolve into the surgical principles taught to successive generations of surgeons including those of today. This thesis sets out to provide a logical sequence of linkages between history, surgical principles and evidence-based medicine by way of an historical review, case studies to illustrate the surgical principles developed from war experiences and evidence-based systematic reviews of contemporary topics on face and jaw war surgery relevant to current combat operations in order to provide recommendations for military surgeons on future deployments. The historical development of face and jaw war surgery was as much about the necessity for innovation and adaptability as it was about the skill of pioneering surgeons such as Gillies, Pickerill and McIndoe. This thesis reviews the major innovations and developments in face and jaw war surgery that came about during major conflicts starting with the First World War and continuing through to current conflicts in Afghanistan. Surgical principles identified from this historical review of war surgery of iii the face and jaws have been illustrated in this thesis by a series of case studies from the Pickerill Collection and archival material from the School of Dentistry, University of Otago which present surgeries performed by Pickerill and his co-workers during the First World War. Discussion on the advances in treatment since Pickerill’s time and illustrative examples of contemporary surgeries performed in Afghanistan provides a comparison between the time periods, highlighting not only the advances in medicine and science since 1918 but also aspects of surgical care that appear to have withstood the test of time. This thesis provides the modern face and jaw surgeon with the necessary historical background and context from which current surgical principles have been developed. By way of evidence-based systematic reviews, the importance and relevance of war surgery of the face and jaws in current military medicine and surgery is highlighted for clinicians and military planners. Current operations in Afghanistan and Iraq have seen a proportional increase in combat related head, face and neck injuries due to the survival of soldiers wearing combat body armour and patterns of injuries resulting from blast fragments. This increase in incidence and the complexity of head, face and neck war surgery, emphasises the need to include surgeons with specialist expertise in this field for future operations. The importance of having an historical perspective in order to appreciate lessons learnt from past conflicts cannot be over-stated. iv ACKNOWLEDGEMENTS This thesis represents the culmination of a number of passions - namely service to others, teaching and surgery. To find a research topic or field that encompasses military history, trauma surgery and academic teaching is rare but I have been fortunate enough to find such a topic which is presented in this thesis. Equally fortunate is the opportunity to work with some very talented and generous people and I gratefully acknowledge my supervisors Professor Robert Love and Professor Tom Brooking for their guidance and patience, my research advisors Professor Ross Beirne and Dr Debra Carr for their input and advice and to Professor Jules Kieser for his mentorship and support throughout this PhD. I am indebted to Dr Andrew Bamji, former curator of the Gillies’ Archive at Queen Mary’s Hospital, Sidcup for his generous support and willingness to share archival material for this PhD. Thanks also goes to the staff at the Hocken Library, University of Otago, the Alexander Turnball Library, Dr Neil Waddell and Professor Murray Thomson, editor of the New Zealand Dental Journal for their kind permission to use images and archival material. My greatest acknowledgement and debt of gratitude is reserved for my wife Catherine, without whom I could not function as a person, husband and father and whose endless patience has allowed me to complete this thesis – Have I told you lately…? Finally, to all those who serve or have served New Zealand, along with their families and extended whanau, Thank you. v CONTENTS DECLARATION CONCERNING THESIS ii ABSTRACT iii ACKNOWLEDGEMENTS v CONTENTS vi LIST OF TABLES ix LIST OF FIGURES x LIST OF ABBREVIATIONS xiii CHAPTER ONE: Introduction 1 Structure of the thesis 17 References 19 CHAPTER TWO: The Development of Face and Jaw War Surgery 21 2.1 The management of maxillofacial injuries prior to the First World War 21 References 29 2.2 Pioneering a specialty 30 References 42 2.3 Maxillofacial surgery in the Second World War 44 References 61 2.4 Modern surgery for modern warfare 64 References 87 2.5 Maxillofacial injuries and urban guerrilla warfare 92 References 105 2.6 Current operations: maxillofacial trauma in Iraq and Afghanistan 107 References 114 vi CHAPTER THREE: Illustrating the Surgical principles 116 3.1 The surgical legacy of Sir Harold Gillies 116 References 122 3.2 Henry Pickerill and the Pickerill Collection 123 References 127 3.3 Case illustration: The management of soft tissue injuries of the face 128 References 137 3.4 Case illustration: The management of fractures of the mandible 138 References 153 3.5 Case illustration: Continuity defects of the mandible 155 References 166 3.6 Case illustration: Mid-face and orbital injuries 170 References 182 3.7 Case illustration: Maxillofacial prostheses 184 References 195 3.8 Lessons learned: principles for the modern military surgeon 196 CHAPTER FOUR: Evidence-Based Systematic Reviews 199 4.1 Evidence-based systematic reviews 199 4.2 Combat body armour and injuries to the head, face and neck region 203 References 220 4.3 Wire intermaxillary fixation and battlefield injuries of the mandible 225 References 249 4.4 Managing maxillofacial trauma in the context of Damage Control Surgery 253 References 266 vii 4.5 Planning for military surgery for future combat operations 268 References 273 CHAPTER FIVE: Summary and Conclusion 274 APPENDICES 278 Appendix One: Major developments in face and jaw war surgery by conflict 278 Appendix Two: List of publications based on thesis research material 280 viii LIST OF TABLES Table 3.8 Adaptation of Gillies’ original surgical principles 197 Table 4.2 Summary of review articles – combat body armour 209 Table 4.3 Summary of review articles – intermaxillary fixation 233 Table 4.4 Summary of review articles – damage control surgery 261 Table 4.5 Levels of military surgical care facilities 270 ix LIST OF FIGURES Figure 1a. Illustration of a duelling scar on the cheek (schmisse) 3 Figure 1b. Prussian military cadets with fresh duelling scars 3 Figure 1c. Bust of Queen Nefertiti 5 Figure 1d. Lt. Col. Howard Kippenberger and Lt. Charles Upham 8 Figure 1e. 2/Lt Buddle, NZ Rifle Brigade 10 Figure 1f. Sir Archibald McIndoe with members of the Guinea Pig Club 11 Figure 2.1a. Line drawing of teeth splinted with gold wire 22 Figure 2.1b. Henry VIII and the Barber Surgeons 24 Figure 2.1c. Ambroise Paré 25 Figure 2.1d. Gunning splint 27 Figure 2.2a. Mid-face traction device in situ 39 Figure 2.2b. Device showing intraoral connectors to external frame 40 Figure 2.2c. Final result of patient 40 Figure 2.2d. Detail of second apparatus for same patient 41 Figure 2.2e.
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