PLASTIC AND COSMETIC SURGERYCHAPTER IHISTORICAL
It seems almost incredible that at this late day so little is generally known to the surgical profession of the beautiful and practical, not to say grateful, art of plastic or restorative surgery, successfully practiced even by the ancients.
The progress of the art has been much interrupted. It is only the later methods of antisepsis, which have so greatly added to general surgery, that have placed it firmly upon the basis of a distinct and separate art in surgical science.
To Aulus Cornelius Celsus, a Latin physician and philosopher, supposed to have lived in the time of Augustus, we owe the first authentic principles of the science. He was a most prolific writer and an urgent worker. After having introduced the Hippocratic system to the Romans he became known as the Roman Hippocrates. His best-known work handed down to us is the “De Medicina,” the first edition of which, divided into eight books, appeared in Florence in 1478. The seventh and eighth volumes, designated the “Surgical Bible,” contain much valuable data in reference to opinions and observations of the Alexandrian School of Medicine.
In considering plastic operations about the face (Curta in auribus, labrisque ac naribus) he writes, “Ratio curationis ejus modi est; id quod curtatum est, in quadratum redigere; ab interoribus ejus angulis lineas transversas incidere, quæ citeriorem partem ab ulterioreex toto diducant; deinda ea quæ resolvimus, in unum adducere. Si non satis junguntur, ultra lineas, quas ante fecimus, alias dua lunatas et ad plagam conversas immittere, quibus summa tantum cutis diducatur, sic enim fit, ut facilius quod adducitur, segui possit, quod non vi cogendum est, sed ita adducendum ut ex facili subsequatur; et dimissum non multum recedat.”
Centuries elapsed before a clear understanding of the above was deduced. Several analyses have been advanced, those of O. Weber and Malgaigne being the most generally accepted.
As shown inFig. 1the method advanced is one for the restoration or repair of an irregular defect about the face in which two transverse incisions forming angular skin flaps, dissected from the underlying tissue, are advanced, joining the denuded free ends.
Should there be a lack of tissue to accomplish perfect coaptation a semilunar incision beyond either outer border is added, as shown inFig. 2, which permits of greater traction, leaving two small quatrespheral areas to heal over by granulation:
Fig. 1.—Celsus Incision for Restoration of Defect.Fig. 2.—Celsus Incision to Relieve Tension.
Fig. 1.—Celsus Incision for Restoration of Defect.
Fig. 1.—Celsus Incision for Restoration of Defect.
Fig. 1.—Celsus Incision for Restoration of Defect.
Fig. 2.—Celsus Incision to Relieve Tension.
Fig. 2.—Celsus Incision to Relieve Tension.
Fig. 2.—Celsus Incision to Relieve Tension.
This is the oldest known reference to plastic surgery of times remote.
From the Orient, however, Susrata in his Ayur-Veda, the exact period of which is unknown, discloses the use of rhinoplastic methods.
For centuries following, and throughout the middle ages, the art seems to have waned and remained practically unknown, as far as is shown in the literature of that period.
A revivalist first appeared about the middle of the fifteenth century in the person of Branca, of Catania, a Sicilian surgeon, who about 1442 established a reputation of building up noses from the skin of the face (exore). His son Antonius enlarged upon his methods and is said to have utilized the integument of the arm to accomplish the same result, thus overcoming the extensive scarring of the face following the elder’s mode. He seems to have been the first authority employing the so-called Italian rhinoplastic method. He is also known to have ventured, more or less, successfully in operations about the lips and ears.
Balthazar Pavoni and Mongitore repeated these methods of operative procedure with more or less success and the brothers Bojanis acquired great celebrity at Naples in the art of remodeling noses.
Vincent Vianeo followed the work of the above.
But, somehow, the heroic efforts of these men dropped so much into oblivion that Fabricius ab Aquapende, in writing of the rhinoplastic work of the brothers Bojani, of Calabria, says: “Primi qui modum reparandi nasum coluere, fuerunt calabri; deinde devenit ad medicos Bononienses.”
That Germany was interested at an early date is shown in the admirable work of a chevalier of the Teutonic Order, Brother Heinrich Von Pfohlspundt, who wrote a book on the subject entitled “Buch der Brundth Ertznei,” with a subtitle, “Eynem eine nawe nasse zu mache.” His volume appeared in 1460, about the time of Antonio Branca, of whose methods he was ignorant, claiming to have learned the art from an Italian who succored many by his skill.
Between the years of 1546 and 1599 Kaspar Tagliacozzi,Professor at Bologna, followed the art of rhinoplasty. His pupils published a book at Venice, describing his work in 1597, entitled “De Corturum chirurgia per insitionem,” which established the first authentic volume in restorative surgery. His operation for restoring the entire nose from a double pedicle flap taken from the arm was declared famous and the operation he then advocated still bears his name.
The great Ambroise Pare knew little of rhinoplasty except what he learned from hearsay. As an instance, he relates in 1575 that “A gentleman named Cadet de Saint-Thoan, who had lost his nose, for a long time wore a nose made of silver and while being much hurt by the criticisms and taunts of his acquaintances heard of a master in Italy who restored noses. He went there and had his facial organ restored, and returned to the great surprise of his friends, who marveled at the change in their formerly silver-nosed friend.”
Now again came a century of forgetfulness, the scientific world taking no cognizance of the work done until, suddenly, in 1794, a message came from Poonah, India, to the effect that an East Indian peasant named Cowasjee, a cowherd following the English army, was captured by Tippo Sahib, who ordered the prisoner’s nose to be amputated. His wounds were dressed and healed by English surgeons. Shortly after this the victim of this odd mode of punishment was befriended by the Koomas, a colony of potters, or, as others claim, a religious sect, who knew how to restore the nose by means of a flap taken from the forehead. They operated on him and restored his nose much to the surprise of Pennant, who reported the case in England.
Shortly following this, and in the same year, cases of similar nature are described in theGentlemen’s Magazine(England), and Pennant’s “Views of Hindoostan.”
In 1811 Lynn successfully accomplished the operation in a case in England, and in 1814 Carpue published hisresults in two cases successfully operated by him by the so-called Hindoo method.
France now took up the art of rhinoplasty. Delpech introduced a modification of the method of the Koomas in 1820, while Lisfranc performed the first operation of this nature in Paris in 1826.
In 1816 Graefe, of Germany, took up the work of Tagliacozzi but modified his method by diminishing the number of operations.
Bünger, of Marburg, thereupon, in 1823, successfully made a man’s nose by taking the necessary tegument from the patient’s thigh.
A still later modification in the art of rhinoplasty was that of Larrey, who in 1830 overcame a large loss about the lobule of the nose by taking the flaps to restore the same from the cheeks.
Among the better advocates of reparative chirurgery were Dieffenbach, v. Langenbeck, Ricard, v. Graefe (1816), Alliot, Blandin, Zeis, Serre, and Joberi, while Thomas D. Mutter, in 1831, published the results he obtained in America—his co-workers being Warren and Pancoast.
Although Le Monier, a French dentist, as early as 1764 originally proposed closure of the cleft in the soft palate, no one attempted to carry out his suggestion until in 1819 the elder Roux, of Paris, performed the operation. The following year Warren, of Boston, independently decided upon and successfully did an improved operation to the same end.
During the years 1865-70 Joseph Lister distinguished himself in the discovery and meritorious employment of carbolic acid as a means of destroying, or at least arresting, infectious germ life, the principle of which, now so fully developed, has advanced the obtainable surgical possibilities inestimably.
The credit of first collecting data of plastic operations belongs to Szymanowski, of Russia. In his magnificentvolume of surgery (1867), he embodies a somewhat thorough treatise on restorative surgery, leaving the subject to be treated more fully and independently, as it should be, to some other enthusiastic surgeon specialist. His work is the result of careful study of such operations on the cadaver, a method much to be recommended to the prospective or operating plastic surgeon.
Several years later, 1871, Reverdin added a valuable method to the still incomplete art, by introducing the now well-known circular epidermal skin grafts for covering granulating surfaces. Thiersch improved this method in 1886 by showing that comparatively large pieces of skin could be transplanted. Wolfe, of Glasgow, had also been successful in utilizing fairly large skin grafts.
Krause, however, improved upon all of these methods by transplanting large flaps of skin without detaching the subcutaneous tissue, a procedure which causes more or less injury to the graft in other methods, and by his method overcoming the subsequent contraction, heretofore a bad feature when the skin-grafted area had healed.
“The results of most plastic operations have been as satisfactory as the most sanguine could hope for or the most critical expect,” says John Eric Erichsen.
Many important additions have been made in the past few years—the outcome of untiring attempt and skill. Czerny replaces part of an amputated breast with a fatty tumor taken from the region of the thigh. Glück successfully repairs a defect in the carotid artery with the aid of a piece of the jugular vein. Glück, Helferich, and others have advocated implanting muscular tissue taken from the dog into muscular deficiencies in the human, due to whatever cause.
The transplantation of a zoöneural section into a defect of a nerve in the human was successfully accomplished by Phillippeaux and Vulpian.
Glück, who later restored a sciatic nerve in a rabbit by the transplantation of the same nerve taken from a hen, went so far as to restore a 5-cm. defect of the radial nerve of a patient by the employment of a bundle of catgut fibers, fully establishing the function of the nerve within a year’s time.
Guthrie has successfully replaced the organs and limbs of animals and has actually transplanted the heads of two dogs.
The transplantation of a toe, to make up a part of a lost finger, is proposed by Nicoladoni. Van Lair hints at the possibility of removing a part or a whole organ immediately before death to repair other living organs.
Von Hippel has successfully implanted a zoöcorneal graft from a rabbit upon the human eye, and Copeland has taken the corneal graft from one human and transplanted it upon the cornea of another to overcome opacity.
The transplantation of pieces of bone to overcome a defect of like tissue has been fully investigated by Ollier, v. Bergman, J. Wolff, MacEwen, Jakimowitsch, Riedinger, and others. They discovered that a graft of bone, with or without its periosteum, can be made to heal into a defect when strict antisepsis is maintained.
Von Nussbaum was the first to introduce the closing of an osseous defect by the use of a pedunculated flap of periosteum.
Poncet and Ollier employed small tubular sections of bone, while Senn has obtained excellent results from the use of chips of aseptic decalcified bone.
Hahn succeeded in implanting the fibula into a defect of the tibia.
On the other hand, cavities in the bones have been successfully filled by Dreesmann and Heydenreich with a paste of plaster made with a five-per-cent carbolic-acid solution, and at a later period by the employment ofparaffin (Gersuny) and iodoform wax, as advocated by Mosetig-Moorhof.
The thyroid glands taken from the sheep, it is claimed, have been successfully implanted in the abdomen of individuals whose thyroid glands had been lost by disease or otherwise.
Protheses of celluloid compound or gutta-percha and painted to resemble the nose or ear have been introduced with grateful result. Metal and glass forms have been used to replace extirpated testicles or to take the place of the vitreous humor of the eye (Mule).
Sunken noses have been raised with metal wire, metal plates, amber, and caoutchouc. Metal plates have been skillfully fitted into the broken bony vault of the cranium.
Lastly comes Gersuny’s most valuable method of injecting paraffin compounds subcutaneously for the restoration of the contour of facial surfaces and limbs, which is rapidly taking the place of extensive plastic transplantory and the much-objected-to metal and bone-plate operations for building up depressed noses and other abnormal cavities.
And the end of possibilities is not yet reached. The successful plastic surgeon has become an imitator of nature’s beauty to-day.
His skill permits of many almost unbelievable corrections of defects that would otherwise evoke the pity and too often the aversion of the onlooker, especially if these occur in the faces of those that have become marred in birth or age, by accident or disease. Withal, it is a noble, generous art, worthy of far more extensive use than it now enjoys.
The above fragmentary references include a number of plastic possibilities. They are introduced only in the sense of general interest to the cosmetic surgeon, the special and detailed subject matter herein given under the various divisions have to do only with plastic and cosmetic operations about the face.