Res Medica, Spring 1965, Volume 4, Number 4 Page 1 of 5

The History and Evolution of Plastic Surgery

A. B. Wallace M.Sc., F.R.C.S. Ed. Reader in Plastic Surgery, University of Edinburgh

Abstract Plastic surgery is a branch coming from the main trunk of medicine and surgery and the origins are in antiquity. Of all branches of medical science plastic surgery is probably the most frequently misunderstood. The word ‘plastic’ is not modern. Today it is used in the main for products of a great modern industry. When one refers to plastic surgery, most people think of cosmetic surgery and unfortunately in some quarters plastic surgery and cosmetic surgery are virtually synonymous. This is far from the case. Again, some persons in ignorance believe that in plastic surgery plastic materials, are used to close wounds and to make scars invisible.

Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk

ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL

Res Medica, Spring 1965, 4(4): 7-10 doi: 10.2218/resmedica.v4i4.435

Wallace, A.B. History and Evolution of Plastic Surgery, Res Medica 1965, 4(4), pp.7-10 doi: 10.2218/resmedica.v4i4.435 HISTORY AND EVOLUTION OF PLASTIC SURGERY

A. B. WALLACE, M.Sc., F.R.C.S.Ed.

Reader in Plastic Surgery, University of Edinburgh

Plastic surgery is a branch coming from the from other individuals and in a limited number main trunk of medicine and surgery and the of cases animal tissues or foreign bodies of origins are in antiquity. animal, mineral or artificial origin. Such trans­ Of all branches of medical science plastic fers are termed transplantations. surgery is probably the most frequently mis­ It is impossible to say when the first plastic understood. The word ‘plastic’ is not modern. operations on man were performed. It can be Today it is used in the main for products of a assumed that grafting in plants, which was great modern industry. When one refers to known in prehistoric times, gives rise to the plastic surgery, most people think of cosmetic idea of transferring tissues in man and animals. surgery and unfortunately in some quarters Progress in surgery has often accompanied plastic surgery and cosmetic surgery are virtually changes in methods of warfare and the nature synonymous. This is far from the case. Again, of mutilation. some persons in ignorance believe that in plastic A common form of injury over the ages was surgery plastic materials, arc used to close loss of the nose. Prehistoric man was at first wounds and to make scars invisible. armed to defend himself only with his hands The confusion is increased by the somewhat and teeth and in close-quarter fighting the nose frequent allusions to the wonders of plastic often suffered. Again, one of the oldest forms surgery in women’s magazines, and readers seem of judicial punishment was surgical removal of to be encouraged to seek cosmetic surgery. the nose. In olden times prisoners of war had A definition of modern plastic surgery would their noses cut off. It is not surprising that the be difficult to offer, but it can be considered as history of plastic surgery is to some extent the repair or reconstruction of tissues following bound up with the development of techniques defects or destruction either congenital or to replace that part of the face lost from sword acquired. A better term would be reconstruc­ injury, gun powder and rifle injury, burns, etc. tive surgery. Some call it the application of techniques to any branch or part of surgery. The word ‘plastic’ comes from a Greek Any part of the body might need repair. The adjective derived from the verb meaning to task of plastic surgery is to restore the appear­ mould or form. It is found in the Latin of the ance and function of parts of the body first century A .D . as plasticus, and by the time destroyed or damaged by disease or injury, parts of the Renaissance it was common use in removed by surgical operation, parts deformed French (plastique) and English. embryologically and to correct physical The root ‘plastic’ has been in continual use deformities. almost from the beginning of the 19th century Plastic surgery attempts to fulfil its purpose when the present era of plastic surgery com­ by transferring to the site of the loss or defect, menced. In 1816 Carpue published a book “An tissues from the adjoining parts, from near or Account of Two Successful Operations for more distant parts of the body and sometimes Restoring a Lost Nose.” Carpue did not actually mention the word but in 1818 Graefe published noses and lips. He also described a method of a book in German, termed “ Rhinoplastic”. and separation of fingers in syndactylism and a in Latin termed “De Rhinoplastice.” plastic operation on the penis to cover the During the next decade a host of new words glans with skin where circumcision had been were coined by tacking the ending ‘plasty’ on to too radical—what might be called penile the Greek names for various anatomical sites, reform. He also described the care of cars e.g. ‘otoplasty’, ‘blepharoplasty’. It is clear, how­ and lips cleft at birth or accidentally torn. ever, that plastic surgery existed long before the Following C elsus there was a long period with­ term plastic was employed. It might well be out progress. considered the oldest branch of surgery. A cultural decline followed the fall of the Portraits dating from 7000 B.C. were recently Roman Empire and the twilight of the Middle excavated around Jericho. Some skulls showed Ages was not favourable to scientific literature. evidence of trephining, presumably to ‘let out The only mention of plastic surgery appeared devils’. Similarly, excavations in ancient Egypt in legends. In Florence there is a fourteenth have brought to light many interesting surgical century picture which shows St. Cosmas and methods in practice about 1600 B.C., for St. Damian transplanting the leg from a Moor instance, the treatment of the dislocated and who had died, to a sexton with cancer of the fractured jaw and fractured nose. leg—an early example of homotransplantation. Some of the oldest records of plastic oper­ History relates how Justinian II (669-711), ations come from India. In the chapters of the Roman Emperor, was so harsh a ruler that his Indian Encyclopaedia, the “Ayurveda”, which subjects rose in rebellion, took the Emperor has been copied from time immemorial, it is prisoner, cut off his nose and sent him into stated that members of the Koomas caste con­ exile. Later he escaped, raised an army, recap­ structed noses from the skin of the face or tured Constantinople and again ascended the forehead for thieves who had been punished by throne. The Emperor naturally demanded a loss of their nose. nasal reconstruction and today, still preserved Books older than “Ayurveda” have been in Venice, is a marble bust of Justinian with a found in Tibetan monasteries and arc said to new nose, evidently constructed from a fore­ contain descriptions of reconstructions of the head flap. Yet, even after this triumph of nose from the skin of the forehead. It is poss­ reconstruction the whole art of facial restor­ ible, therefore, that this knowledge spread to ation disappeared from recorded history for India in the stream of cultural influence which more than 700 years. emanated from Tibet into the countries of the In A.D. 1215, Pope Innoccnt III decreed that East. no priest should perform any surgical operations It is in some ways surprising that the Bible which involved bloodshed and as a result pro­ contains no mention of plastic operations if cedures were turned over to barbers, bath- we except the verse in Genesis “and the rib keepers, executioners, mountebanks and other which the Lord God had taken from man, individuals of low degree. And so the next made he a woman.” There arc likewise no genuine records of plastic operations from Italy records in the Talmud. Even the Greek poet are not found until the middle of the 15th Homer, who loved to describe many types of century. In 1442, Branca, a surgeon of Catania wounds and their treatment, did not mention in Sicily, carried out plastic repairs of the nose, the possibility of replacement of lost parts. using skin from the face. His son, Antonio, The first European writer to mention plastic continued his work and was the first to replace operations was a Roman doctor, Aurelius the nose by a flap of skin from the arm. Cornelius Celsus, who lived in the time of The Brancas themselves left no writings but Tiberius Caesar. Celsus gave detailed accounts in 1460 Heinrich von Pfolspenridt, a Bavarian of many techniques to repair loss of tissue of army surgeon, wrote on the flap-from-the-arm the nose, lips or ears. method used by the Brancas. Their technique In A.D. 30, Celsus wrote “De Re Medica”, was also written up by Fioravanti in 1549. He the oldest medical document after the writing observed their secret work and wrote—“and of Hippocrates. Celsus could be called the everyday I went to their house for they have father of plastic surgery. In his book he five persons on whom to make noses, and when describes the first operative correction for they wished to perform these operations they ectropion, ptosis, and entropion of eyelids. He called me to watch such a thing, and I turned repaired with local skin flaps mutilated cars, my face away but my eyes saw very well, and thus I saw the whole secret from the beginning In October 1794 the Indian method of rhino­ to end and I learned it.” plasty by means of a forehead flap was brought It was after seeing the Brancas at work that to the attention of European surgeons by an the Roman poet, Elisio Calenzio, wrote of using anonymous letter in the “Gentlemen’s Maga­ the nose from a slave to graft to a mutilated zine” from two English observers who had person. Voltaire, in his Philosophic Dictionary seen a Mahratta surgeon perform it in India. in 1792, wrote in the following lines of homo­ This letter stimulated Joseph Carpue, a student grafts— * at St. George’s Hospital and later surgeon to the Duke of York’s Hospital, Chelsea, to perform, “ And so Tagliacotius in 1814, the first rhinoplasty in Europe in A famous Aesculapius modern times. His work stimulated surgeons in Restored the missing nose. some European countries, e.g. Graefe in Ger­ Listen I pray to this prose many, but had little influence in Britain. I low in a strange way Britain, in the latter half of the 19th century, He cut some skin away lagged behind and produced little in recon­ From the bottom of a slave structive surgery. It is interesting, however, to And applied it swiftly note that the principles of plastic surgery were To the face adroitly evolved before “Listerism” . It was however But there came the time alas, papers in this period that extended plastic When death of donor came to pass surgery to all parts of the body—not only the The recipient’s nose did follow face but the extremities. And then alas within the coffin The descriptions up to now have been all Landed nose did join the bottom.” referable to ‘flap’ transplantations in the recon­ struction of missing parts. Even before flaps The first systematic treatise on plastic were employed, the tilemaker caste in India surgery ever written was published in 1597 by are said to have successfully utilised free graft G aspar Tagliacotius, the Professor of Surgery transplantations of skin, including the sub­ at Bologna. In his book he describes in detail cutaneous fat, taken from the gluteal region, his pedicled arm flap for rhinoplasty. after it had been beaten with a wooden slipper Tagliacotius’ temerity in interfering in the until a considerable amount of swelling had affairs of the Almighty found great disfavour in taken place. This process of beating was the eyes of the dignitaries of the Church. He termed ‘flagellation’. The Indians used a secret was excommunicated and his corpse was ex­ cement for the adhesion and the procedure was humed from its grave in a monastery church termed the ‘Ancient Indian Method’. Flagel­ and placed in unconsecrated ground. The lation brought more blood to the part. The citizens of Bologna, however, were so proud of removal of tissue from one part of the body their countryman that a monument was erected to another was termed ‘free grafting” . and the figure holds a nose in its hand. For Up to the beginning of the 19th century some time after Tagliacotius’ death his pupils little further was done in relation to the trans- continued his operations, but during the 17th plantation of free grafts of skin. In 1869 and 18th centuries plastic surgery was almost Revcrdin reported on grafting of small discs of completely neglected. In the 17th and 18th skin to ulcers and he was followed by Ollier, centuries no great importance was attached to Thiersch and Wolfe. men or women with missing noses and they Even in the early 20th century there was had substitutes made of gold, silver or ivory. little interest in plastic surgery in Britain and In 1731 a female charlatan, Gambacurta, in 1914 reconstructive surgery had not one offered for sale her healing balsam in the streets single exponent; it was considered purely a of Florence. She would cut a piece of flesh minor aide to the general surgeon to epitheli- from her thigh, pass it round on a plate, get it alisc raw surfaces and was not often practised, confirmed in writing by the town clerk and The outbreak of war in 1914 with its mounting then apply the piece of flesh to the wound toll of severe facial casualties showed the again. On treating it with the balsam, she got medical world the poverty of its surgical recon­ healing without a scar. structive resources. The trench, or static warfare, produced high proportions of missile •Modified from E. V. ELST. Physiopathology and Treat­ ment of Burns, J. Lorthiow. Presses Academiqres injuries of the head and face. Europen—Brussels, 1964. In 1916 the British Dental Association held

9 a discussion on “The Treatment of Injuries of iable percentage of all admissions. Treatment the Face and Jaw” in London. The German may include not only wide excision of the surgeons, with intelligent collaboration of lesion but also all the regional nodes in con­ surgeon and dentist, had obviously forged ahead. tinuity. In the face, the first step may be a A Major Gillies had served with the Red Cross tracheostomy and then a hemiresection of the in France from November 1915 and had seen jaw. Later extensive reconstructive procedures the results obtained by French plastic surgeons will be required. and dental surgeons and, on returning to Unfortunately to the lay mind a plastic England, set up a unit of 200 beds at Cam­ surgeon continues to be looked 011 as a beauty bridge Hospital, Aldershot. Later a move was surgeon. The amount of cosmetic surgery, made to Queen’s Hospital, Frognal, Sidcup, however, carried out by plastic surgeons outside Kent, at first with 320 beds but later expanded the London area is less than 2 per cent, of all to over 600. The unit was termed a maxillo­ their work. Essentially a plastic surgeon is a facial unit and was staffed by plastic surgeons reconstructive and functional surgeon, one who and dentists. Many became famous—Gillies by training and practice shares a place with his and Kilner of Britain, Davis of America, and colleagues in the family of surgeons. His pat­ Magill, the anaesthetist. ients suffer from loss of functions and/or dis­ Between the two world wars plastic surgery figurement. entered a difficult phase. The possibilities of Since World War II most universities have the speciality in peace-time were not apprec­ recognised the specialty. The plastic surgeon iated. By 1930 there were only two plastic takes part in the teaching of the undergraduate surgeons in Britain. At the outbreak of World and postgraduate medical student and he also War II Britain had only four fully experienced plays a part in research. He has helped to plastic surgeons and several centres were set up revolutionise the treatment of burns, and has to train young surgeons in the methods of led in the studies of skin homografts, skin pre­ World War I. servation and synthetic skin. H e has helped in The problems of World War II were how­ the development of modern anaesthesia. He ever in many ways quite different from World has stimulated orthopaedic studies of facial War I. World W ar I was a static war but World abnormalities. War II was one of movement with severe Many tissues can be grafted. Skin, fat, carti­ injuries due to high speed crashes, crushes, lage and bone grafts are common, but musclcs, burnings and fractures. The injuries were not vessels, nerve and organs can be transplanted. confined to the face but were of the trunk and Homografts and heterografts are used and extremities. The plastic surgeon found himself tissues can be preserved.. If the homograft on much more equal terms with his general and rejection response is conquered a new extensive orthopaedic colleagues. Many units were set up. field of replacement surgery will be opened. Since World War II most universities have Grafts can be applied to any part of the recognised the specialty and brought added body—ears, eyebrows, eyelids, nose, lips, chin, responsibilities in teaching and research. fingers, foot, etc. What then does modern plastic surgery If parts cannot be made in flesh they arc attempt? As has been said, plastic surgery made in artificial material. is the application of special techniques—of Not only human beings benefit from plastic careful handling, of transplantations, etc. The surgery, but also animals. Valuable dogs can field is wide but not fixed. Patients of all ages be saved from destruction by excision of mali­ with tissue defects are accepted. gnant cutaneous lesions and grafting. In the newborn there are cleft lips and The plastic surgeon has also played a promin­ palates, defects of first arch, fused fingers, birth ent part in accident prevention, especially marks, etc. Many forms of accidents are relating to burns. accepted, maxillo-facial injuries, degloving in­ The plastic surgeon cannot rest on his laurels juries, crush injuries of hands, finger injuries, but, with his surgical colleagues, can continue wringer injuries and severe burns. Over 30 per to help his fellow men. Surgeons from advanced cent of all admissions to the South East countries have tremendous responsibilities to Scotland Regional Plastic Unit are the results other countries. They can play a tremendous of acute trauma. part in breaking down international barriers Skin cancers and oral cancers form an apprec­ by teaching and helping.

10