Sunday, 17 November 2013

F - Facial Reconstruction

So this week I came across an engraving from Gasparo Tagliacozzi's On the Surgery of Mutilation by Grafting (1597). I've seen this image a few times, but every time I see it I always feel the need to share it with people. I'm usually met with comments such as 'that's disgusting' and 'why aren't you working?', but I'm hoping that my small and intermittent blog audience will be more favourable. F is for facial surgery, or facial reconstruction.

Tagliacozzi's work built upon that of Antonio Branca, who is regarded by many as being the first to develop the so-called 'Italian method' of rhinoplasty. Although never documenting his work, contemporary correspondence provides sufficient evidence to suggest what Branca's technique involved. For example:

Orpianus, if you would have your nose restored, come to me, Truly, the thing is wonderful. Branca, a Sicilian, a man of great ability, has learned the art of restoring a nose, either by supplying it from the arm of the patient, or by infixing upon the part the nose of a slave. Having seen this, I determined on writing to you, to whom no news can be more interesting. Be assured, that if you come, you may go home again with as much nose as you please.

As was stated here, and portrayed in this incredible image, surgeons using the 'Italian method' would attempt to cut a perfectly-shaped flap of skin from the patient's arm and attach it to their nose. This piece of skin, known as a pedicle, would remain attached, and the arm  would then be bandaged and strapped into this position seen here. The patient would remain this way for a three or four weeks, or until the constructed piece of skin had fused to the face. The pedicle would then be severed and the new skin refashioned into a nose.

It is not known what the demand would be for procedures such as this, but in a world where syphilis was rife, it was no doubt an attractive idea for those that could afford it. Wealthy men and women could have turned to surgical reconstruction, or simply purchased an artificial nose seen here, to avoid the public disdain that accompanied this disfiguring disease. This nineteenth-century watercolour by Thomas Godart shows the ulceration of the nose as a result of syphilis.

Unfortunately, however, this method was not as enduring as other, more effective, rhinoplasty procedures, such as the 'Indian Method' which used skin from the forehead to sculpt the nose. It is perhaps also due to the high risks of infection that surgery of this kind only really developed in the nineteenth and twentieth centuries. It was possibly the First World War that contributed to the greatest developments in skin transplants and advanced facial reconstruction. Harold Gillies became the twentieth-century pioneer of this procedure, and is known today as the 'father of plastic surgery'.

Born in New Zealand in 1882, Gillies joined the Royal Army Medical Corps following the outbreak of the war, and it is here that he learned the necessity of facial surgery for wounded soldiers. Soon, under his instruction, an initial ward, and then an entire hospital, was created to deal with the vast numbers of burned and disfigured servicemen who were transported back to London. Due to the ongoing risk of infection from procedures such as these, Gillies developed the tubed pedicle graft method. This saw a flap of skin from the forehead or chest being pulled across and attached to the required area of the face. The flap itself was then stitched together to form a tube, so that the blood flow could remain to the transported piece of skin, thus considerably reducing the risk of infection.  A series of photographs of this procedure can be seen below. Gillies is reported as being the first to use the term 'reconstructive surgery' and he was later knighted for his services in 1930 as he continued to develop his techniques, which he again put into practice during World War Two.

  • Images provided by the Wellcome Library's Images Collection
  • J. Jacques, Rhinoplasty and Facial Plastic Surgery (Phoenix, 1987)
  • Gasparo Tagliacozzi's On the Surgery of Mutilation by Grafting (Bologna, 1597)


Davis Nguyen said...

It's fascinating how much history tells as far as facial reconstruction is concerned. How much has change or remained continues to give us an idea of how it was done back then. There's methods and cures to be drawn from past trials, and past maladies that these have tried to address. What's undeniable is that facial reconstruction has always been embraced, and can be seen as civilizations strive for progress and development. There is a historic purpose to be had with this, and not just the cosmetic or the in-thing.

Dr. Davis Nguyen

Paul Middleton said...

Thank you for taking the time to comment on this post Davis, I really appreciate your thoughts.

Yevette Behnke said...

Who would have thought that a military man is the first one to try reconstructive surgery? Well, I am really thankful that you posted this information, Paul. It's nice to know how objective these reconstructive surgeries are when they started. I hope more patients and practitioners will take note of its importance.

Yevette Behnke @ US HealthWorks