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Plastic Surgery Volume 1 - Principles
History of reconstructive and aesthetic surgery
S YNOP S I SOrigin of plastic surgery
Origin of plastic surgery In Ancient Egypt
Origin of plastic surgery In Mesopotamia
Origin of plastic surgery In India
Origin of plastic surgery In Greece
Origin of plastic surgery In Rome
S YNOP S I S
History shows that almost every possible local flap has been described in the past and that the ingenuity of plastic surgeons was unlimited.
The lesson drawn from history reveals that the so-called new flaps are variations of what has already been published.
We have to be humble and recognize that “nothing is new under the sun.”
Gaspare Tagliacozzi (1545–1597), from Bologna, Italy, defined plastic surgery as the art devoted to repairing congenital or acquired defects (“to restore what Nature has given and chance has taken away”), and which has as its primary goal the aim of correcting a functional impairment, but also re-establishing an appearance as close as possible to normality (“the main purpose of this procedure – he writes – is not the restoration of the original beauty of the face, but rather the rehabilitation of the part in question”).1 The term “plastic” comes from the Greek πλαστικóς (plasticós), moldable.
Origin of plastic surgery
The distant past
The ancient origin of plastic surgery relates to the healing of wounds. Management of wounds caused by stones, weapons, arrows, and animal bites goes back millions of years, when primitive humans had to face four major problems: (1) arrest of posttraumatic loss of substance; (2) bleeding; (3) infection; and (4) pain.
Attempts to transform a defect that heals slowly by secondary intention into one healing quicker by primary intention may well account for the first example of a reparative procedure.
However, this must have been quite complex without appropriate tools, in the presence of hemorrhage and without anesthesia. There is no documentation of stitching of wounds among primitive people.2 We may extrapolate from what was reported in ancient Hindu medicine, where wound edges were sewn with simple means like fibers or strips of tendon, or pinned together using insect mandibles.
Origin of plastic surgery In Ancient Egypt
We are well informed about Egyptian surgery thanks to the Smyth papyrus, the most ancient medical text. The papyrus is a later transcription (about 1650 BC) of an original manuscript dating from the Old Kingdom (between 3000 and 2500 BC). It describes 48 surgical cases, including wounds, fractures, dislocations, sores, and tumors, and suggests their potential management.
Fresh wounds were treated conservatively with the application of grease and honey using linen and swabs.
Adhesive strips of cloth, stitches or a combination of clamp and stitches were advocated to bring together the margins of the wound. A surgical knife was never mentioned, as wounds already existed in the cases presented.2 Treatment of nasal fractures is accurately explained. First, clots should be removed from the inside of the nostrils, then the bony fragments repositioned; two stiff rolls of linen were applied externally “by which the nose is held fast” and finally “two plugs of linen saturated with grease placed into the nostrils.”3
Origin of plastic surgery In Mesopotamia
Mesopotamia is the region between the rivers Tigris and Euphrates (now approximately Iraq) where Sumerian civilization was born. Medicine was well developed, although strongly influenced by astrology and divination.
During excavations of the Nineveh palace, a great library containing more than 30 000 clay tablets with cuneiform inscriptions was discovered, 800 of them of a medical nature. They were written about 600 BC, although the text dates from around 2000 BC. The tablets of interest for plastic surgery are few and concern wound healing or congenital anomalies. “If a man is sick with a blow on the cheek, pound together turpentine, tamarisk, daisy, flour of Inninnu (…) mix in milk and beer in a small copper pan; spread on skin and he shall recover.”4 Another tablet suggests the use of a dressing with oil for an open wound.
Monsters (congenital malformations) were considered important in predicting future events and in determining their course. “When a woman gives birth to an infant (…) whose nostrils are absent, the country will be in affliction, and the house of the man ruined; that has no tongue the house of the man will be ruined; that has no lips affliction will strike the land and the house of the man will be destroyed.”5 Interestingly, surgery is never mentioned in clay tablets, although surgery was certainly performed. In the King Hammurabi Code,2 dating from about 1700 BC, surgical malpractice was recognized with precise laws: “If a physician carried out a major operation on a seignior with a bronze lancet and has caused the seignior’s death or he opened the eye socket of a seignior and has destroyed the seignior eye, they shall cut off his hand.” “If a physician carried out a major operation on a commoner’s slave with a bronze lancet and has caused [his] death, he shall make good slave for slave.”
Origin of plastic surgery In India
The birth of plastic surgery has a close correlation with the art of reconstructing noses. This apparently curious origin has a logical explanation if one considers the common tradition of certain ancient populations of mutilating the nose of adulterers, thieves and prisoners of war as a sign of humiliation. In an attempt to improve this terrible disfigurement, surgeons invented different solutions over the centuries.
In India, amputation of the nose was rather common and repair was carried out by the Koomas, a low caste of priests, or, according to others, a guild of potters. In the Áyurvédam, the Indian sacred book of knowledge which deals with medicine, the missing portions of the nose were reconstructed using local flaps transposed from the cheek. An accurate description of blunt (yantra) and sharp (sastra) instruments necessary to perform surgical operations in general and rhinoplasty in particular is supplied.6
It is not possible either to establish the exact date of the work (it is thought to have been written about 600 BC), or to prove that Sushruta, the author, was one man.
On the contrary, there is evidence that over the centuries various Indian surgeons contributed to describe the procedures included in the book. When was the forehead skin used? There is no mention of it. In the second half of the 17th century, the Venetian adventurer Nicolò Manuzzi (1639–1717) wrote a manuscript about the Moghul empire in which an account of forehead rhinoplasty is supplied. Regrettably the manuscript, kept in the Marciana Library at Venice, was not published until 1907.7 Information on the forehead flap in nasal reconstruction only reached the western world at the end of
the 18th century, thanks to a letter signed BL, addressed to Mr. Urban, editor of the Gentleman’s Magazine, and published in October 1794 (Fig. 2.1).8
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Origin of plastic surgery In India |
A friend of mine has transmitted to me, from the East Indies, the following very curious and, in Europe, I believe unknown chirurgical operation, which has long been practiced in India with success; namely, affixing a new nose on a man’s face.
There follows the accurate description of the two-step procedure carried out on Cowasjee, a bullock driver of the English army, who fell under the disfavour of Tippoo Sultan, who had his nose amputated. It demonstrates the high level of surgery reached by the Indians in carrying out an operation, without anesthesia, in a very similar way to what we perform nowadays.
Origin of plastic surgery In Greece
Greek medicine was influenced by Hippocrates, the greatest physician of his time. Historians consider that Hippocrates was born in the island of Kos around the year 460 BC, and probably trained in medicine at the Asklepieion of Kos. In ancient Greece and Rome, the Asklepieion (Latin: aesculapı¯um) was a healing temple, sacred to Asklepios, the Greek god of medicine.
Hippocrates rejected the views of his time that illness was due to supernatural influence, possession of evil spirits, or disfavor of the gods. He based his medical practice on the direct observation of disease and on an analysis of the human body, introducing scientific methods into medicine. Hippocrates taught and practiced medicine throughout his life, traveling in various Greek regions. He established the Great School of Medicine on the isle of Kos. He probably died in Larissa (Greece) at the age of 83 or 90.
About 70 medical treatises, assembled during the Alexandrian era (third century AD), were attributed to Hippocrates. They form the so-called Corpus Hippocraticum.
Whether Hippocrates himself is the author of the Corpus and these works are authentic has been the
matter of great dispute and controversy.9 The Corpus contains manuals, lectures, research, philosophical thoughts, and essays on different topics of medicine, without any logical order and even with significant contradictions among them. The works of Hippocrates were true best-sellers, reprinted numerous times over the centuries. The first printed edition of the Opera omnia (Complete Works) was issued in Latin in Rome in 1525, and in Greek in Venice in 1526 by the Aldine Press.
The surgical knowledge of Hippocrates was vast. He used cauterization for the management of raw surfaces, reduced malunited fractures, and practiced cranial trephination to evacuate hematomas.
Origin of plastic surgery In Rome
In Rome, surgery was well developed, at least judging from the rather sophisticated bronze instruments discovered in Pompei and now kept at Naples National Museum. Many were stored in traveling kits to be used by surgeons for emergency or in the battlefields.
The two most representative figures of Roman medicine were Celsus and Galen.
Aulus Cornelius Celsus (25 BC–50 AD) was probably not a physician, but a writer from a noble family and the author, in about 30 AD, of De Medicina (On Medicine) in eight volumes. In book seven, chapter nine, vessel ligature and lithotomy as well as lip closure (cleft lip or lip tumor) by means of flaps are reported. It explains how “defects of the ears, lips and nose can be cured” (curta in auribus, labrisque ac naribus, quomodo sarciri et curare possint), followed by a description of wound
closure by advancement flap.10 “The defect should be converted into a square (in quadratum redigere). Then, from the inner angles transverse incisions are made (lineas transversas incidere), so that the part on one side is fully divided from that on the opposite side.” “After that, the tissues which have been undermined, are brought together” (in unum adducere). “If this is not possible two additional semilunar incisions are made at some distance from the original (ultra lineas, quas ante fecimus, alias duas lunatas et ad piagam conversas immittere), but only sectioning the outer skin. […] These latter incisions enable the parts to be easily brought together without using any traction” (Fig. 2.2). Celsus holds a key role in the history of plastic surgery, as he is considered the earliest writer on this topic. He is responsible for introducing the four cardinal signs of acute inflammation, “redness and swelling with heat and pain” (rubor et tumor, cum calore et dolore).
A copy of Celsus’s manuscript was discovered in Milan in 1443, and printed for the first time in 1478
in Florence.11 De Medicina went through more than 50 editions.
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Lip repair according to Celsus.
(Reproduced from Nélaton C, OmbredanneL. Les Autoplasties. Paris, Steinheil, 1907.)
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Claudius Galen (c. 129–201 AD) was born in Pergamon (Turkey), studied medicine at the Asklepieion (see above) in his native city and moved to Rome. He wrote about head traumas, techniques of trephination for evacuating hematomas and various types of bandaging.
An excellent anatomist, he described more than 300 muscles and seven pairs of cranial nerves and contributed to neurology, demonstrating that nerves arise from the brain or spinal cord. He observed that section of the laryngeal nerve resulted in dysphonia. For management of wounds he used sutures and cautery.
Numerous works of Galen were lost, but 82 survived. Originally written in Greek, many were translated into Arabic and Latin. Galen’s Opera was first printed in Latin in Venice in 1490 and in Greek at Venice in 1525 by the Aldine Press.
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| History of reconstructive and aesthetic surgery |
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