The History and Evolution of Plastic Surgery

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 HISTORY AND EVOLUTION OF


Reader in Plastic Surgery, University of Edinburgh
Plastic surgery is a branch com ing from the main trunk of m edicine and surgery and the origins are in antiquity.
O f all branches of m edical science plastic surgery is probably the m ost frequently m is understood. T h e word 'plastic' is not m odern. T od ay it is used in the m ain for products o f a great modern industry. W h e n one refers to plastic surgery, m ost people think of cosm etic surgery and unfortunately in som e quarters plastic surgery and cosm etic surgery are virtually synonym ous. T h is is far from the case. Again, some persons in ignorance believe that in plastic surgery plastic materials, arc used to close wounds and to m ake scars invisible.
T h e confusion is increased by the som ewhat frequent allusions to the wonders of plastic surgery in w om en's magazines, and readers seem to be encouraged to seek cosm etic surgery.
A definition of modern plastic surgery would b e difficult to offer, b u t it can be considered as the repair or reconstruction of tissues follow ing defects or destruction either congenital or acquired. A better term would be reconstruc tive surgery. Som e call it the application of techniques to any branch or part of surgery. A n y part of the body m ight need repair. T h e task of plastic surgery is to restore the appear ance and function of parts of the body destroyed or damaged by disease or injury, parts removed by surgical operation, parts deform ed em bryologically and to correct physical deformities.
Plastic surgery attem pts to fulfil its purpose by transferring to the site of the loss or defect, tissues from the adjoining parts, from near or more distant parts of the body and som etim es from other individuals and in a lim ited num ber of cases animal tissues or foreign bodies of anim al, mineral or artificial origin. Such trans fers are term ed transplantations.
It is im possible to say w hen the first plastic operations on man were perform ed. It can be assumed that grafting in plants, w hich was know n in prehistoric times, gives rise to the idea of transferring tissues in man and animals. Progress in surgery has often accom panied changes in m ethods of warfare and the nature of m utilation.
A com m on form of injury over th e ages was loss of the nose. Prehistoric man was at first armed to defend him self only w ith his hands and teeth and in close-quarter fighting the nose often suffered. Again, one of the oldest forms o f judicial punishm ent was surgical rem oval of the nose. In olden tim es prisoners of war had their noses cut off. It is not surprising that the history of plastic surgery is to som e extent bound up w ith the developm ent of techniques to replace that part of the face lost from sword injury, gun powder and rifle injury, burns, etc.
T h e word 'plastic' com es from a G reek adjective derived from the verb m eaning to m ould or form. It is found in the Latin of the first century A .D . as plasticus, and by the tim e of the Renaissance it was com m on use in French (plastique) and English.
T h e root 'plastic' has been in continual use alm ost from the beginning of the 19th century when the present era of plastic surgery com m enced. In 1816 C arpue published a book " An A ccou n t of T w o Successful O perations for Restoring a Lost N ose." C arpu e did not actually m ention the word but in 18 18 G raefe published a book in G erm an , term ed " R h in o plastic" . and in Latin term ed " D e R h inoplastice ." D urin g the next decade a host o f new words were coined by tacking the ending 'plasty' on to the G reek nam es for various anatom ical sites, e.g. 'otoplasty', 'blepharoplasty' . It is clear, how ever, that plastic surgery existed lon g before the term plastic was em ployed. It m ight well be considered the oldest branch o f surgery.
Portraits dating from 7000 B .C . were recently excavated around Jericho. Som e skulls showed evidence o f trephining, presum ably to 'let out devils'. Sim ilarly, excavations in ancient E gyp t have brought to ligh t m any interesting surgical m ethods in practice about 1600 B .C ., for instance, the treatm ent o f the dislocated and fractured jaw and fractured nose.
S om e o f the oldest records of plastic oper ations com e from India. In the chapters of the Indian Encyclopaedia, the " A yurveda" , which has been copied from tim e im m em orial, it is stated that m em bers o f the Koom as caste con structed noses from the skin o f the face or forehead for thieves who had been punished by loss o f their nose.
Books older than " A yurveda" have been found in T ib etan m onasteries and arc said to contain descriptions o f reconstructions of the nose from the skin o f the forehead. It is poss ible, therefore, that this know ledge spread to India in the stream o f cultural influence which em anated from T ib e t into the countries of the East.
It is in som e ways surprising that the B ib le contains no m ention o f plastic operations if we except the verse in G enesis " and the rib which the Lord G o d had taken from m an, m ade he a w om an." T h ere arc likewise no records in the T alm u d . E ven the G reek poet H om er, who loved to describe m any types of wounds and their treatm ent, did not m ention the possibility of replacem ent o f lost parts.
T h e first European w riter to m ention plastic operations was a R om an doctor, Aurelius Cornelius C elsus, who lived in the tim e of T ib eriu s Caesar. C elsus gave detailed accounts of m any techniques to repair loss o f tissue of the nose, lips or ears.
In A .D . 30, C elsus wrote " D e R e M ed ica" , the oldest m edical docum ent after the writing of H ippocrates. C elsus could be called the father of plastic surgery. In his book he describes the first operative correction for ectropion, ptosis, and entropion of eyelids. H e repaired with local skin flaps m utilated cars, noses and lips. H e also described a m ethod of separation of fingers in syndactylism and a plastic operation on the penis to cover the glans with skin where circum cision had been too radical-w hat m ight be called penile reform . H e also described the care of cars and lips cleft at birth or accidentally torn. Follow in g C elsus there was a long period w ith out progress.
A cultural decline follow ed the fall of the Rom an E m p ire and the tw ilight o f the M id d le Ages was not favourable to scientific literature.
T h e only m ention of plastic surgery appeared in legends. In Florence there is a fourteenth century picture which shows St. Cosm as and St. D am ian transplanting the leg from a M oor who had died, to a sexton w ith cancer of the leg-an early exam ple o f hom otransplantation.
H istory relates how Justinian II (6 69 -711), R om an Em peror, was so harsh a ruler that his subjects rose in rebellion, took the E m p eror prisoner, cut off his nose and sent him into exile. Later he escaped, raised an arm y, recap tured C on stan tin op le and again ascended the throne. T h e Em p eror naturally dem anded a nasal reconstruction and today, still preserved in V enice, is a m arble bust of Justinian w ith a new nose, evidently constructed from a fore head flap. Y e t, even after this trium ph of reconstruction the whole art of facial restor ation disappeared from recorded history for more than 700 years.
In A .D . 1 2 1 5 , Pope Innoccnt III decreed that no priest should perform any surgical operations which involved bloodshed and as a result pro cedures were turned over to barbers, bathkeepers, executioners, m ountebanks and other individuals of low degree. A n d so the next genuine records of plastic operations from Italy are not found until the m iddle of the 15 th century. In 1442, Branca, a surgeon o f Catania in Sicily, carried out plastic repairs of the nose, using skin from the face. H is son, A ntonio, continued his work and was the first to replace the nose by a flap of skin from th e arm .
T h e Brancas them selves left no w ritings but in 1460 H einrich von P folspenridt, a Bavarian arm y surgeon, wrote on the flap-from-the-arm m ethod used by the Brancas. T h e ir technique was also written up by Fioravanti in 1549. H e observed their secret work and wrote-" and everyday I w ent to their house for they have five persons on whom to m ake noses, and when they wished to perform these operations they called me to watch such a thing, and I turned m y face away but m y eyes saw very w ell, and thus I saw the w hole secret from the beginning to end and I learned it." It was after seeing the B rancas at work that the R om an poet, E lisio C alenzio, wrote of using the nose from a slave to graft to a m utilated person. T h e first system atic treatise on plastic surgery ever written was published in 15 9 7 by G a s p a r Tagliacotius, the Professor of Surgery at B ologna. In his book he describes in detail his p edicled arm flap for rhinoplasty.
T agliaco tiu s' tem erity in interfering in the affairs o f the A lm igh ty found great disfavour in the eyes of the dignitaries of the C hurch. H e was excom m unicated and his corpse was ex humed from its grave in a m onastery church and placed in unconsecrated ground. T h e citizens of B ologna, however, were so proud of their countrym an that a m onum ent was erected and the figure holds a nose in its hand. F o r som e tim e after T agliaco tiu s' death his pupils continued his operations, but during the 17th and 18th centuries plastic surgery was almost com pletely neglected. In the 17th and 18th cen turies no great im portance was attached to m en or w om en w ith m issing noses and they had substitutes m ade of gold, silver or ivory. In 1 7 3 1 a fem ale charlatan, G am bacurta, offered for sale her healing balsam in the streets o f Florence. She would cut a piece of flesh from her thigh, pass it round on a plate, get it confirm ed in w riting b y the town clerk and then apply the piece o f flesh to the wound again. O n treating it with the balsam , she got healing w ithout a scar.
•M odified from E. V. E LS T. Ph ysiop a th ology and T r e a t m ent o f Burns, J. L orth iow . Presses A cadem iqres Europen-Brussels, 1964. In O ctober 179 4 the Indian m ethod o f rhino plasty by m eans o f a forehead flap was brought to the attention o f European surgeons by an anonym ous letter in the " G en tlem en 's M aga zine" from two E nglish observers who had seen a M a hratta surgeon perform it in India. T h is letter stim ulated Joseph C arp u e, a student at St. G eo rge's H ospital and later surgeon to the D uke o f Y o rk 's H ospital, Chelsea, to perform , in 1 8 14, the first rhinoplasty in E u ro p e in m odern times. H is work stim ulated surgeons in som e European countries, e.g. G raefe in G e r many, bu t had little influence in Britain.
Britain, in the latter half of the 19th century, lagged behind and produced little in recon structive surgery. It is interesting, however, to note that the principles o f plastic surgery were evolved before " L isterism " . It was however papers in this period that extended plastic surgery to all parts o f the body-not only the face but the extrem ities.
T h e descriptions up to now have been all referable to 'flap ' transplantations in the recon struction of m issing parts. E v e n before flaps were em ployed, the tilem aker caste in India are said to have successfully utilised free graft transplantations of skin, including the sub cutaneous fat, taken from the gluteal region, after it had been beaten w ith a w ooden slipper until a considerable am ount o f sw elling had taken place . T h is process o f beating was term ed 'flagellation' . T h e Indians used a secret cem ent for the adhesion and the procedure was term ed the 'A n cien t Indian M e th o d '. Flagel lation brought m ore blood to the part. T h e removal o f tissue from one part o f th e body to another was term ed 'free grafting" . U p to the beginning of th e 19 th century little further was done in relation to the transplantation o f free grafts o f skin. In 1869 R evcrdin reported on grafting o f small discs of skin to ulcers and he was follow ed by O llier, T h iersch and W o lfe . E ven in the early 20th century there was little interest in plastic surgery in B ritain and in 19 14 reconstructive surgery had not one single exponent; it was considered purely a m inor aide to the general surgeon to epithelialisc raw surfaces and was not often practised, T h e outbreak of war in 19 1 4 w ith its m ounting toll of severe facial casualties showed the m edical w orld the poverty o f its surgical recon structive resources. T h e trench, or static warfare, produced high proportions o f m issile injuries of the head and face.
In 19 16 the British D ental Association held a discussion on " T h e T reatm en t of Injuries of the Face and Ja w " in Lon don. T h e G erm an surgeons, with intelligent collaboration of surgeon and dentist, had obviously forged ahead. A M ajo r G illies had served with the R ed Cross in Fran ce from N ovem ber 1 9 15 and had seen the results obtained by French plastic surgeons and dental surgeons and, on returning to England , set up a unit of 200 beds at C a m bridge H ospital, A ldershot. L ater a m ove was m ade to Q u een 's H ospital, Frognal, Sidcup, K ent, at first with 320 beds but later expanded to over 600. T h e unit was term ed a m axillo facial unit and was staffed by plastic surgeons and dentists. The problem s o f W o rld W a r II were how ever in m any ways quite different from W orld W a r I. W o rld W a r I was a static war but W o rld W a r II was one of m ovem ent with severe injuries due to high speed crashes, crushes, burnings and fractures. T h e injuries were not confined to the face but were of the trunk and extrem ities. T h e plastic surgeon found him self on m uch m ore equal terms w ith his general and orthopaedic colleagues. M an y units were set up. Since W o rld W a r II m ost universities have recognised the specialty and brought added responsibilities in teaching and research.
W h a t then does m odern plastic surgery attem pt? As has been said, plastic surgery is the application of special techniques-of careful handling, of transplantations, etc. T h e field is w ide but not fixed. Patients o f all ages with tissue defects are accepted.
In the newborn there are cleft lips and palates, defects of first arch, fused fingers, birth marks, etc. M an y form s o f accidents are accepted, m axillo-facial injuries, degloving in juries, crush injuries of hands, finger injuries, wringer injuries and severe burns. O ver 30 per cent of all adm issions to the South East Scotland Regional Plastic U n it are the results of acute trauma.
Skin cancers and oral cancers form an apprec iable percentage o f all adm issions. T reatm en t m ay include not only w ide excision o f the lesion but also all the regional nodes in con tinuity. In the face, the first step m ay be a tracheostom y and then a hem iresection of the jaw. Later extensive reconstructive procedures will be required. U nfortunately to the lay m ind a plastic surgeon continues to be looked 011 as a beauty surgeon. T h e am ount of cosm etic surgery, however, carried out by plastic surgeons outside the London area is less than 2 per cent, of all their work. Essentially a plastic surgeon is a reconstructive and functional surgeon, one w ho by training and practice shares a place w ith his colleagues in the fam ily of surgeons. H is p at ients suffer from loss of functions an d /o r dis figurem ent.
Since W o rld W a r II m ost universities have recognised the specialty. T h e plastic surgeon takes part in the teaching of the undergraduate and postgraduate m edical student and he also plays a part in research. H e has helped to revolutionise the treatm ent of burns, and has led in the studies of skin hom ografts, skin pre servation and synthetic skin . H e has helped in the developm ent of modern anaesthesia. H e has stim ulated orthopaedic studies of facial abnorm alities.
M any tissues can be grafted. Skin, fat, carti lage and bone grafts are com m on, but m usclcs, vessels, nerve and organs can be transplanted. H om ografts and heterografts are used and tissues can be preserved.. If the hom ograft rejection response is conquered a new extensive field of replacem ent surgery will be opened.
G rafts can be applied to any part of the body-ears, eyebrows, eyelids, nose, lips, chin, fingers, foot, etc.
If parts cannot be m ade in flesh they arc m ade in artificial m aterial.
N ot only hum an beings benefit from plastic surgery, but also anim als. V alu ab le dogs can be saved from destruction by excision of m ali gnant cutaneous lesions and grafting.
T h e plastic surgeon has also played a prom in ent part in accident prevention, especially relating to burns.
T h e plastic surgeon cannot rest on his laurels but, with his surgical colleagues, can continue to help his fellow m en. Surgeons from advanced countries have trem endous responsibilities to other countries. T h e y can play a trem endous part in breaking down international barriers by teaching and helping.