Plastic Surgery Origins and the Antipodean Influence

What follows may not be proven truth, rather anecdotal slant and circuitous, non-malicious licence in the telling ... “I've heard it said, at least I think that's what they said, by whom I've forgotten ...” spices meals and makes history more digestible. Like much of Plastic Surgery itself, which is more art than science, comparisons with this ‘control’ are not evidence-based but a product of truths, myths and legends. Reconstructive surgery's illustrious and dubious past is outlined and Australasian contributions are showcased in the context of international surgical evolution.

Tagliacozzi had a few followers who repeated successful cases but despite the fame of the procedure today, over the course of time it fell into disuse. It was thought to be either impossible or fabulous and his success was eventually declared apocryphal. 3 In the early twentieth century Jacques Joseph  It had been offered to him earlier by Kaiser Willhelm on the condition that he converted to christianity but he refused. In 1931 he published his milestone book on plastic surgery-Nasenplastik und sonstige gesichtsplastik, nebst einem anhang über mammaplastik. 4 Joseph gave the first description of the deltopectoral island flap for breast surgery and neck resurfacing 5 which includes a copy of a picture from Carl Manchot's 1889 atlas on cutaneous arterial anatomy, 6 specifying the arterial basis for the flap. Manchot, while still a medical student, was tasked by his neurology professor to chart the course of the cutaneous arteries assuming that they followed the nerves, his primary focus of intent.
The nerves did not reliably follow arteries and the work, which proved to be a veritable treasure map for subsequent flap design, was shelved and thought to be lost to humanity by those who could only read English until its 'rediscovery' in the 1970s.
One hundred and sixty years later, Felix Behan, in Melbourne, showed that arteries did broadly follow the dermatome pattern and described his angiotome concept of skin blood supply 7  Paré also reports in his treatise that he did not persist with the balm recipe given to him by the surgeon to the King made from boiling puppies but instead advocated onions. His most famous phrase at the end of his treatise on wounds is 'I dressed the wound and God healed him'. In the mercenary world of today this is more commonly stated as 'God heals and the doctor sends the bill'. Having previously reattached three of his own son's fingers, he was presented with a finger amputation at the middle phalanx level. He took the precaution of obtaining signed affidavits from witnesses who saw the finger before and after his reattachment so as not to be marred by claims of charlatan, a common problem of that era. Balfour next saw his patient one month later and noted that the nail had fallen off and the skin had desquamated but the finger was 'the handsometh the man has and had recovered both heat and sensation'. Gibson accredits Gottlieb Hoffacker, doctor to the dualists of Heidelberg, with the most critical and credible observations, and hence the most valuable, in predicting success of free grafting amputated parts.

Quoting from Gibson:
He analysed reported cases, including 16 of his own amputated nose tips and lips sustained from duelling incidents. He observed that contrary to common understanding, completely severed parts were not yet dead and the most predictable parameters for rescue were washing away blood, oblique amputation, and delay. The latter allowed bleeding to stop, the severed part to relax from its contracted state to its original dimension and for its blood vessels to reopen allowing lymph fluid exuding from the cut wound to re-enter the now open ends. Replantation of the part facilitated accurate and maximum primary adhesion over the largest recipient area and favoured first, rather than second, intention healing. These parameters appear obvious today as those which would most favor graft take, but it is of note that at this period, nearly 40 years before Revedin reported his skin grafting in 1870, it was generally accepted that wounds could only heal by secondary intention. 11 Jacques-Louis Reverdin, a young Genevan intern in the department of Guyon in Paris, was aware of Theodor Billroth's observations that some wounds appeared to heal from expanding islands of presumed surviving epithelial remnants. He therefore implanted tiny pieces of skin from the arm to a thumb defect and obtained complete wound healing. In 1869 he presented his case to the Societe Imperiale de Chirurgie. It was the first demonstration that skin could survive for a period detached from the body, that it could regain a circulation and that once grafted it could expand.
Reverdin returned to Geneva where with his cousin described myxedema and its association with thyroidectomy. Emil Theodor Kocher was the sole recipient of a nobel prize for almost parallel work on the thyroid, a prize that many believed should have been shared with the Reverdins.
Jacques retired and dedicated himself to the study of butterflies. Louis Ollier and Karl Tiersch soon showed that larger grafts were also possible. So it was that a curious chapter in the history of plastic surgery, zoografting, came into being and is again described in a fascinating article by Gibson. 12 This involved grafting of living tissue from one species to another, the recipient being human.
Frog skin was most popular because it was cheap and could be carried in the surgeon's pocket 13 although dog puppies, rabbits and birds were also tried. Although many of the writers wrote with extravagant and misplaced enthusiasm, remarkably some of those who performed the grafts, including Reverdin, believed that the grafts did survive and were responsible for their wounds eventually healing. Reverdin felt that, although surviving, they did not grow but stimulated the surrounding granulations to metamorphose into epithelium which then covered the wound. 14 Allen 13 quoted Stricker's view of the existence of sexes in the tissues: The colonies of epithelial corpuscles at the edges remain quiescent through lack of one sexual element, which the grafts no sooner supply than reproduction rapidly sets in, fertilisation being brought about through the medium of the fluid which bathes the surface of the granulations. If the sexual theory accounts for the process, the skin that grows after the application of the frog grafts must be of a new breed, a cross between human and frog epidermal elements.
What we have now learned from immunology means that these were clearly false inter-pretations of apparently correct observations. Even before The assistant retired from surgery and became a green-grocer. 19 In the light of the risks and technical challenges it was therefore extraordinary that      In reality they had discovered what Sushruta, Manchot, Esser and Joseph had published long before. This territorial vascularization has since been definitively articulated by G Ian Taylor in his book, The angiosome concept and tissue transfer. 48 With the blinkers now lifted it was obvious to many that a purely cutaneous flap based on these single source vessels was ripe for transfer. The race was set for the world's first free skin flap transfer and the modern era of plastic surgery would begin.