A brief history of plastic surgery
Elizabeth Bullivant takes us on a whistle stop tour from the Egyptian beginnings of the specialty, through its evolution, to its present day form
Edivence of reconstructive surgery exists in Egyptian medical papyruses that date back to 1600 BC
As surgical specialties go you may think that plastic surgery is one of the best known at the moment, courtesy of media coverage of celebrity "enhancements" and the never ending pursuit of the perfect appearance. Plastic and cosmetic surgery have, in the eyes of the public, become almost interchangeable terms, but in medical and historical contexts this isn't so. Cosmetic surgery involves elective procedures performed for aesthetic reasons, but plastic surgery refers to surgical reconstruction of deformity, providing normal appearance and function.
The specialty developed from its ancient Egyptian origins more than three thousand years ago. It progressed geographically, as knowledge disseminated from epicentres, including northern India at about 600 BC, Sicily in the 15th century Renaissance, Germany in the 19th century, and finally Britain in the two world wars.
Egyptian beginnings
Evidence of reconstructive surgery exists in Egyptian medical papyruses that date back to 1600 BC, describing reconstructive techniques employed by the priest-doctors of the time to restore appearance.
Pair of sketches from Karl Graef's Rhinoplastik
Of these, the Edwin Smith Surgical Papyrus is the best example, describing case histories and advice for practical management, unlike other texts, which outlined combinations of magical and practical techniques. Of the 48 preserved, case 12 describes how to approach "a break in the chamber of the nose," including a description of its appearance and methods of packing the nasal cavity to stop bleeding and reproduce a normal profile. Also included are suturing techniques, which allowed large lacerations to heal with minimal scarring.
In the upper echelons of Egyptian society huge importance was placed on appearance, as shown by the elaborate death masks of the pharaohs and their everyday use of make up. Therefore, a person's appearance was altered, doctors were expected to restore it to normality, and it was this demand that provided the stimulus for the foundations of plastic surgery. Although lack of anaesthesia and pain relief and religious forbiddance of invasive surgery limited their work to superficial injuries, doctors were able to perfect basic but highly effective techniques, which continue to be used today.
Reconstructing the nose in India
Almost a thousand years later, a Hindu doctor, Susruta, working in northern India close to the modern day city of Varanasi, made the next step in the development of plastic surgery, with the introduction of rhinoplasty. Nasal amputation was common at the time, either through injury on the battlefield or as a punishment, which produced a shocking and disfigured appearance.
McIndoe's technique were used on this soldier, in 1944, who had a nose reconstruction and skin graft
In response, Susruta developed a reconstruction technique that returned some degree of function and form, which is described in his book, Samhita (about 600 BC). His work spread quickly to eastern Europe and into the Byzantine empire, where, in AD 700 the emperor Justinian successfully had a forehead rhinoplasty after a traumatic nasal amputation. Surviving statues of Justinian bear scars around the nose and forehead, a testament to the surgery he underwent.
The fall of the Roman empire in the fifth century was crucial in preventing the dissemination of this technique throughout western Europe. Lack of demand for procedures other than rhinoplasty in the east meant a lack of driving force for further advancements; techniques were only being refined not pioneered.
It was not until the Renaissance in the 15th century that any developments took place. Italian practitioners were at the forefront, as for many medical advances at that time, specifically a Sicilian family of surgeons, the Brancas. Between Branca Senior and his son, Antonius, suturing techniques were refined, affording minimal scarring, new methods for repairing wounds to ears and lips were established, and the aforementioned Indian method was introduced to the West, as Susruta's text became more widely available.
Pioneering wound healing
Working in the 16th century in Bologna, a surgeon named Gaspare Tagliacozzi began to experiment with the use of pedicles, which involves relocating a section of skin, subcutaneous tissues, and vasculature to another area to cover a wound.
Although correct in principle and practice, Tagliacozzi's techniques were not popular among his peers, and without a successor to take over, his work was disregarded until interest in reconstructive techniques resurfaced in the 19th century. It has been suggested that interest waned because of skin transplantation experiments that Tagliacozzi and others had attempted, and the widely held belief of the time that the recipient would survive only as long as the donor remained alive.
Although there were sporadic developments in the discipline after Tagliacozzi, including Ambrose Pare's revolutionary advances in wound healing, discouraging the use of cautery in favour of natural healing, the next milestone was not reached until the early 19th century and Karl von Graefe's coining of the name "plastic surgery" for the specialty. This was from the Greek "plastikos," which means to mould or give form to.
At the time other countries, including Britain, were reviving the Indian method, after a description of the procedure being carried out in India was published in the Gentleman's Magazine in London in 1794. Von Graefe's publication of Rhinoplastik in 1818 signalled the beginning of a new chapter, with innovative rhinoplastic techniques being developed. Johann Dieffenbach, who succeeded von Grafe, ensured continuity. The profile of reconstructive surgery was maintained with the publication of the groundbreaking Operative Chirurgie in 1845, which was the first practical text to describe the principles and techniques of reconstructive surgery, so the procedures could be replicated by other surgeons.
As with other surgical pioneers of the period, Dieffenbach benefited greatly from advances in the fundamentals of surgical practice, with the introduction of anaesthesia and antiseptic techniques. This allowed more intricate procedures to be attempted, with a greater degree of precision, coupled with a reduced risk of postoperative infection, driving success rates upward. Dieffenbach has been credited with the title of "father of plastic surgery," which may have come to him as much because of the hard work of others, including Joseph Lister and James Simpson, as his own.
Ready to improve appearances
By the end of the 19th century, aesthetics, as well as function, became an important part of plastic surgery. As the mechanics of reconstruction were perfected, attention turned to developing techniques to restore as normal an appearance as possible. The first successful skin graft is attributed to the English surgeon Astley Cooper, who, in 1817 used the technique during a thumb amputation.
A reliable, replicable technique was not described until 1869, when Jacques Louis Reverdin showed the use of full thickness grafts in the treatment of large wounds. This triggered a spiral of rapid progress, in which grafting was perfected in a range of tissue, from eyelids, by George Lawson, to mucous membranes, by Czerny. The importance of this work was perhaps underestimated at the time, but its legacy was massive, ensuring that basic techniques had been developed, honed, and advanced.
War drives surgical progress
Twentieth century warfare heralded a new age in weaponry, accompanied by the inevitable progression in battlefield injuries. Shrapnel wounds from heavy artillery, burns from explosives, and traumatic amputations were common. During the second world war, reliance on aerial combat increased and planes became more advanced, with larger fuel tanks and a greater capacity for munitions. This meant that although pilots were more likely to survive if shot down, they were at a greater risk of suffering serious burns.
As for many other surgical specialties, war was a massive force in the shaping of plastic surgery, providing both the opportunity and the need for advancements in practice. It has been speculated that in the six years of the second world war, progress was made equivalent to that in 50 years of peace. Focusing on the work of two New Zealanders, Harold Gillies and Archibald McIndoe, we can briefly explore the amazing work that took place, the difference it made to the patients involved, and its positive reshaping of societal attitudes.
During the four years of the first world war Gillies's work centred on the treatment of facial deformities, from orthopaedic jaw injuries to the reconstruction of burnt eyes, lips, and noses. Aside from the medical techniques, Gillies's attitudes towards his patients helped improve society's opinions of people with facial disfigurement. Previously, such patients would have covered their disfigurement with a mask, a practice perhaps more stigmatising than their underlying injury. Once they had had surgery, however, Gillies's patients were encouraged to act normally and were integrated back into their previous life, to the best of their ability. A summary of this work, Plastic Surgery of the Face, was published in 1920.
A knighthood in 1930 recognised the gravity of Gillies's work and its continuing progression was ensured with the arrival of McIndoe. In the years before the second world war started, McIndoe worked for his cousin Gillies, perfecting reconstructive techniques, so that when the time came he was ready to take any wounded at the East Grinstead Hospital, where he worked, although it was not until the Battle of Britain in 1940 that severe facial burns became a more common injury.
As his workload increased, McIndoe set about creating not just surgical techniques to repair visible injuries, but a whole rehabilitative centre, designed to tackle the range of the patient's needs, aiming to reintegrate them into society. The horrific nature of the injuries, meant it would have been easy for morale to slip, hindering recovery, but through careful planning, including the employment of "only the prettiest nurses", a relaxed atmosphere was created on the ward, aiding the success of McIndoe's new surgical techniques. Such was the camaraderie generated, that the patients formed the Guinea Pig Club, the title reflecting the nature of the surgery being done, and surviving members continue to meet to the present day.
These new procedures included adventurous uses of pedicles, stretching in some cases from chest to face, reconstruction of eyelids, and relocation of the big toe to the hand to replicate the action of a thumb, restoring function and minimising disability. Some patients recovered so successfully that they were able to return to their squadrons and fly again.
Our times
Recent history sees a merging of plastic with cosmetic surgery, a byproduct of our image fuelled, appearance obsessed society. The most recent advances, notably partial face transplants, are a testament to this desire to always look "normal." Although accurate and correct in the medicine involved, the motives behind such cosmetic procedures are very different to those shaping the development of plastic surgery.
Initially, reconstructive techniques were only the preserve of the ruling classes, with war widening this to the bravest members of society as well. The work undertaken by McIndoe and Gillies placed a strong emphasis on making the patient feel accepted as part of society and able to live a normal life. In a way, the choice that we now have, in the form of elective cosmetic procedures, is a continuation of that ideal. It is now driven by patients' desire rather than necessity and is available to all with the means to pay.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
1 Ghalioungui P. Magic and medical science in ancient Egypt. London: Hodder and Stoughton, 1963.
2 Wallace AE. The progress of plastic surgery. Oxford: Willem A Meeuws, 1982.
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4 Backstein R, Hinek A. War and medicine: the origins of plastic surgery. Univ Toronto Med J 2005;3:217-9.
5 Watts MT. The history of oculoplastic surgery. Facial Plast Surg 1993;9:151-7.
6 Williams P, Harrison T. McIndoe's Army. 2nd ed. London: Sphere, 1981.
Elizabeth Bullivant, student, University of Birmingham
Email: Exb268@bham.ac.uk
Student BMJ 2007;15:427-470 ISSN 0966-6494 | December
