..

Chapter 1

The principles and purpose of plastic surgery-past and present

M. Felix Freshwater, M.D.

The principles and purpose of plastic surgery are related intimately. Rather than being mesmerized by memorized facts of so-called historical irsts, we should understand the development of plastic surgery in terms of accepted principles of historical investigation. Similarly, instead of performing plastic surgical procedures blindly, we should understand the principles which allow us to be creative both in the practice of the art and in the design of solutions for plastic surgical problems. In the solution of these problems, we must have purposes and goals for the patient, the surgeon, and society. THE PAST

Standing at the three-quarter mark of the twentieth century, two of the most exciting recent developments of interest to plastic surgeons have been replantation surgery and the neurovascular island Aap. However, historical research reveals that both replantation of digits and use of the neurovascular island Aap were developed early in the nineteenth century. What is the signiicance of this? ( Is this merely another example of the admonition that someone who thinks that he has invented a new surgical procedure simply has not read the German literature? ) Seeking historical irsts by deciding who irst described disease X or performed procedure Y or tried technique Z is doomed to failure because one can never be positive that a given person described, performed, or tried something before everyone else. Instead it is wise to adhere to the principles of priority best expressed by Sir Francis Darwin and Sir Richard Owen. It was these principles that Sir William Osler used to decide who deserved credit for the

discovery of general anesthesia. Owen said, "He becomes the true discoverer who establishes the truth; and the sign of the proof is the general acceptance."22 Darwin said, " In science, the credit goes to the man who convinces the world, not to the man to whom the idea irst occurred. Not to the man who inds a grain of new and precious quality, but to him who sows it, reaps it, grinds it, and feeds the world on it."10 Let us examine the development of the neurovascular island Aap and inger replantation in terms of Owen's and Darwin's principles. The neurovascular island lap

At irst glance, it might seem that the history of the neurovascular island Aap is the history of the vascular island Aap. The vascular island Aap evolved from the work of Theodore Dunham 11 of New York, George Monks21 of Boston, and Joachim Von Esser28 of whatever country he happened to be traveling through at the moment. In 1893 Dunham described a two-stage operation: in the irst stage, a scalp Aap based on the supericial temporal artery was raised and implanted into a defect of the malar area; at the second stage, Dunham deepithelized that part of the Aap above the supericial temporal artery, dissected it away from the lateral parts of the flap's pedicle, retuned the lateral parts of the pedicle to the donor site, and buried the deepithelized Aap in an incision connecting the malar area to the donor site.

Acknowledging Dunham's work, Monks in 1898 created the one-stage island Aap procedure with which we are familiar today. As can be seen in Fig. 1- 1, Monks palpated the course of the supericial temporal artery, made an mJsJon

3

4 Bsic principles

A B

E

Fig. 1-1. Vascu lar island flap to reconstruct lower eyelid from Monks. (From Mon ks, G. H . : Boston Med. Su rg. J. 139:385, 1898; cou rtesy ational Library of Medicine, Bethesda, Md.)

through the skin (Fig. 1-1, A), and dissected out the artery and its surrounding tissues (Fig. 1-1,B). He created a tunnel between the forehead and the defect of the lower eyelid as seen in Fig. 1-1, C, pulled his island Aap through the tunnel (Fig. 1-1, D), and closed the defect with tissue of the island Aap (Fig. 1-1, ).

Von Esser (Fig. 1-2) used Monks' island Aap and performed some variations on it in reconstructing maxillofacial trauma in soldiers during and after World War I. It was Von Esser who irst named island Aaps in his paper from the New York Medicaljoumal of 1917. The neurovascular island

Aap as known today was developed by Littler19 in the United States and by Tubiana and Duparc27 in France for use in surgery of the hand.

However, it is abundantly clear that the neurovascular island Aap was developed in the early part of the nineteenth century. Let us trace the events that led to the development of this Aap. The broadside shown in Fig. 1-3 was published in India in 1794 and in London in 1795.30 The broadside describes the case of Cowasjee, a bullock driver for the British Army in India who had his nose cut off when he was captured by the enemy. A tilemaker from a local caste reconstructed a nose for

--

;_ --

Fig. 1-2. J oachim F. S. Von Essen. (Cou rtesy N ational Library of M edici ne, Bethesda, M d . )

111'.. . , , _ \.,. ,,,Ar,, t - ."' . . ' !!'_ .. .It, ... --

()J}R. \TIOX. .-

.....J ... ...... . -

Fig. 1-3. Cowasjee broadside by J ames Wales. (Courtesy N ational Library of Medicine , Bethesda, Md.)

A

F; -

.tr

c

Fig. 1-4. A, Preoperative engraving of Carpue's irst patient. B, I m mediate postoperative engaving of Carpue's i rst patient. C, Preoperative and late postoperative engraving ofCarpue's second patient. (From Carpue,J. .: An accou nt of two successfu l operations for restoring a lost nose, London, 1 8 1 6, Longman. Hu rst. Rees, Orme, & Brow n; cou rtesy National Library of Medicine , Bethesda, Mel.)

B

.

The principles and purpose of plastic surgey-past and present 7

Cowasjee using a forehead lap rotated into the defect, with the donor site being left to heal by contraction. Records at the India Ofice Library indicate that several copies of this broadside were ordered for Sir Joseph Banks, President of the Royal Society and famous naturalist. 14 Banks was a close friend of Joseph Constantine Carpue, an anatomy teacher in London, who became fascinated with the broadside-often recounting Cowasjee's tale to his anatomy students. Carpue8 began experimenting on cadavers on whom he created forehead laps and then applied the results of these experiments to create noses for returning mutilated veterans of the Napoleonic wars.

In 18 16 Carpue published a book entitled An Account f Two Successful Opeations for Restoring a Lost Nose With the Integuments of the Forehead in the Cses f Two Oicers of Hs Majesty's Army, in Which are Included Hstorical and Physiological Remarks on the Nasal Opeation Including Descriptions f the Indan and Italan Methos. Carpue reviewed the fact and folklore of plastic surgery up to his time. In Carpue's book are excellent engravings by Charles Turner, shown in Fig. 1-4, depicting Carpue's preoperative and postoperative results. What is especially striking about these engravings is the honesty with which they are depicted, showing that the patient did not have a perfect lifelike nose at the end of the procedures. Carpue's book was an immediate success and led to a renaissance of reconstructive surgery. Shortly after his book was published, Carpue became one of the few surgeons ever to be elected to fellowship in the Royal Society of London. His book was translated into German,9 with Carl Von Graefe, Professor of Surgery in Berlin, having written a foreword to it. In 18 17 Von Graefe29 published his own book,

Rhinoplastik, and for the irst time the word "plastic" was used to describe a reconstructive operation. Finally, in 1838 Zeis published his Handbuch der plastichen Chirurgie, 31 which reviewed the literature of plastic surgery up to that time, and with the publication of this book, plastic surgery was given its name.

With this brief overview of plastic surgery at the beginning of the nineteenth century, let us look at an interesting article that appeared in the Journal Universal et H ebdomaaire in Paris in 183 1.1 The article was the minutes of the December 19, 183 1 meeting of the Institute of the Academy of Sciences and Reports and contains a case report by Philippe Blandin. An abstract of these minutes appeared in the Medical-Chirurgical Review of 1832.3 This abstract is signiicant for two reasons.

First, it shows that Blandin's report was not buried in an obscure corner of the medical literature but was published in another journal in another country. Second, the abstract is a translation from French into English made in the same era, and this eliminates errors of interpretation that might occur in a more modern translation. The abstract is as follows:

The patient , had been long affected with an enormous cancer of the nose , wh ich had resisted every treatment. M. B land i n , having com pletely excised the diseased part, detached from the forehead a Aap of integument , and shaped i t to the stu m p of the nose; but he did not d iv ide the ped icle of the Aap as had usual ly been done; instead of doi ng th is, he separated the ski n from i t a n d then c u t away t h e integu ments from the root of the nose; the opposite raw su rfaces were brought together, and quickly u n i ted. By this maneuver, the new nose conti n u ed to retain i ts com m u n ication with the blood vessels and nerves, which im parted l i fe to i t at i rst, and was thereby m uch stronger and less l i kely to be affected by cold , and other accidents.*

Thus in 183 1 Blandin (Fig. 1-5) described the use of the neurovascular island lap. Unlike Dunham, Monks, and Von Esser, he purposely mentioned preserving the blood vessels and nerves going to the lap to improve function. In 1836 *From A nonymous: Rhinoplastic operation , Med. Chir. Rev. 1 7: 1 7 2 , 1 832 .

Fig. 1-5. Phi l ippe Blandin. (Cou rtesy National Library of Medicine, Bethesda, Md.)

8 Bsic principles

Blandin published his book De l'Autoplastie. 7 The main points of De l'Autoplastie were that it was advisable to preserve the pedicle of the forehead lap when rotated into place for rhinoplasty because if this pedicle were to be divided prematurely the lap would die. Furthermore, if there appeared to be too much tension when the pedicle was rotated into place, it was advisable to separate the vessels from the remainder of tissues in the pedicle and rotate them separately. Blandin said that by this maneuver, one could decrease the amount of torsion on these vessels and thereby preserve the integrity of the lap. Despite the description of the neurovascular island lap having been published in France and knowledge of this publication having spread to England, there is no evidence that the use of the neurovascular island lap became an accepted procedure. Indeed two years before Dunham's report, the monumental French Traiti de Chirurgie12 mentioned the problem of lap necrosis in forehead laps and suggested the use of an axial lap made wide enough to include the supratrochlear artery; no mention was made of the supratrochlear nerve or vein. Therefore it appears that Blandin was more than a century before his time and that this early example of a neurovascular island lap does not fulill Owen's and Darwin's criteria for discovery, despite its interest as a plastic curiosity.

Fig. 1-6. Leonardo Fioravan ti. (Courtesy National Library of M edici n e, Bethesda, Md.)

Replantation of digits The history of replantation surgery is older

than that of plastic surgery. Indeed Saints Cosmos and Damian, the patron saints of surgery, are credited with having performed the irst successful composite tissue homograft in their miraculous transplantation of an entire lower extremity from one person to another. The irst example of replantation that is often cited is the story told by Leonardo Fioravanti13 (Fig. 1-6) in his book of 1570, Il Tesoro Della Vita Humana. Fioravanti recounts an incident that occurred when he was in Africa. A Spanish gentleman had his nose cut off in a duel. Fioravanti urinated on the amputated nose, replaced it in its proper position, and dressed the wound. About 8 or 10 days later, he removed the dressing and observed a completely healed nose. Fioravanti's anecdotal account, like others that succeeded it, was not believed.16 Realizing this, William Balfour5 took great care when he submitted "Two Cases, with Observations, Demonstrative of the Powers of Nature to Reunite Parts which Have Been, by Accident, Totally Separated from the Animal System" to the Edinburgh Medical and Surgicaljounal in 1814.

Balfour's irst case was that of his 4z-year-old son who sustained incomplete amputations of the distal phalanges of three ingers that were crushed in a door. Balfour's second case was that of George Pedie, a carpenter, who accidently amputated his own left index inger with a hatchet. According to Balfour:

I exam ined the wound, and found it began near the u pper end of the second phalanx, on the th u m b side a n d terminated about t h e third phalanx on the opposite side. The amputated piece, as measu red by the patient h i msel f, was an inch-and-a-hal f long, on the thumb side, and an i nch on the other. (The wou nd was i n fl icted in the c leanest man ner by one stroke of a hatchet, and term inated i n an acute point.) About 5 minu tes, as nearly as l can guess, Thomas Robertson retuned with a piece of fi nger, which was wh ite and cold; I remarked o DL Reid, who was present , that i t looked and fel t l i ke a b i t of ca ndle. Without the loss of a moment, I poured a stream of cold water on both wounded surfaces, to wash away the blood from one, and any d irt that might be ad hering from the otheL I then appl ied, wi th as m uch accuracy as possible, the wounded surfaces to each other, expressi ng a conident expression that reu n ion wou ld take place.*

* From Balfour, W.: Two cases, w i th observations, demonstrative of the powers of nat u re to reu ni te parts wh ich have been , by accident, tota l ly separated from the an imal system , Edin. Med. Surg. J. 1 0 :42 1 , 1 8 1 4 .

The principles and purpose of plastic surgey-past and present 9

Balfour found that adhesion did take place. And because, as he said, "It must be confessed, that instances of the reunion of parts which had been entirely separated are very rare in the human body, so rare that most practitioners still treat with disbelief and ridicule those instances which have been put on record," he included copies of afidavits by George Pedie, Thomas Robertson, and Peter Reid, which were witnessed by Duncan Cowen, a Justice of the Peace (Fig. 1-7).

Here is an example of the successful replantation of a cleanly amputated inger. What role does Balfour play in the history of plastic surgery? What credit does he deserve for the development of re-

Dr Balfour on tre Rm1ion f Se>rrall Part1. 429 1, GEORGE PEnm, house-carcntcr, declare, That, onthc Oth .1y of .June last,. when at work 111 the Advocates' J.ihr.rv, 1 occidcntly struck .oil the inger nxt the thumb .of my left h;,n

10 Bsic principles

Guy's Hospital. As they appear in the catalogue, these notes state2:

A copy of the cu rious and valuable papeL H artield , a you n g man admitted i n to Gu y's H ospital (Conel ius Ward), Apri l 9 , 1 8 1 7 , wi th a d i seased th u m b which M r. Cooper, now Sir Astley, ampu tated between the phaln ges 01 the 1 8th of J u ly. He then cut off a heal thy ptce .of mtegu ment from the a m pu tated part and apphed t t to the face of the stu m p where he secu red it by means of ad hesive s l ips. First week to J u ly 2 5 , u n ion seems to have taken place. Second week th-ough August I , M r. Cooper proved the vascu lari ty of the newly attached portion by prick ing i t very s l igh tly with the poin t of a lancet w h ich p-oduced luid loss as readi ly as from any other part of the l imb, sensibi l i ty has not yet retuned. Thid week from the operation , in the cou rse of t h i s week sensation was restored in the end of the stu mp. September 2 5 , the stu m p appeared qu ite wel l . Note : th i s patient , l th i n k , resided in Kitcham.*

One might think that this case is reason to credit Cooper with developing skin grafting. Indeed he principle. that Cooper used in applying the skm graft, that IS, using the portions of an amputated part for salvage of the remaining tissues, was relearned recently in the twentieth century. However, as with Saints Cosmos and Damian and Fioravanti, there is no evidence that Cooper's case as duplicted let alone widely accepted at the ume. A bnef account of this case was published by Franz Reisinger25 in the Bayersche Annalen fur Abhandlungen, Eindungen und Beobachten aus dem Gebiete der Chirurgie, Augenheilkunst und Geburtshulte for 1824. Reisinger's account of the case is buried in a footnote in a paper on experimental corneal transplantation. The Bavarian Annals was an obscure jounal that lasted less than a year, and only one copy is known to exist in the United Kingdom and another copy known to exist in the United States. Therefore, although Cooper's case of skin grafting was published, he cannot be c.redited with having made a signiicant contributun to. the development of skin grafting. As an aside, It should be mentioned that skin grafting did not become accepted until it was popularized by Pollock in 1870. s PRINCIPLES OF PLASTIC SURGERY

The foregoing discussion should reinforce the iea that just s one should not investigate the history of plastic surgery without adhering to the fundamental principles of the history of science

*From A.nonymou s : M.S catalogue of S ir Astley Cooper's preparations , H u n tenan M u seu m , Royal College of Su rgeons , London.

Fig. 1-8. Sir H arold Del f Gil l ies, ci rca 1 932. (Cou rtesy D. Ralph M i l lard , M . D . )

such as those of Darwin and Owen, so one should not perform plastic surgery without a thorough understanding of its principles. It is these principles that provide the interface between the scientiic facts and the clinical art of plastic surgery.

The year was 1920, and the world was recovering from the holocaust, the terror, and the destruction of World War I. It was a time for assessing damage and reconstructing and reforming the face of an earth that had been mutilated by the trauma of war. England had been spared from the sword, and although her soil was not scarred, her men were. At this time of repair-this time of healing of the wounds of war-Major Harold Delf Gillies (Fig. 1-8) was responsible for reconstructing the horrible deformities of the English forces. Gillies17 summarized his experience in his book, Pastic Surgey of the Face. In the irst chapter of his book, Gil!ies outlined the principles of plastic surgery, which developed by trial and error as he perfected his plastic surgical knowledge and technique. The following principles are as important and relevant today as they were when irst published by Gillies more than half a century ago:

l. Obtain a history. 2 . Mistakes in d iagnosis due to inadequate exam

i nation are perhaps the com monest cause of ind ifferent treatment.

3. Make a record. 4 . Al l ormal tissues should be replaced as early as

posstble and maintai ned in its normal posi t ion.

The principles and purpose of plastic surgey-past and present II

Fig. 1-9. D. Ralph Mi l lard , ci rca 1 955 . (Cou rtesy D. Ralph Mi l lard , M.D.)

5. In plan n ing the restoration , fu nction is the fi rst consideration , and i t i s indeed fortu nate that the best cosmetic esults are, as a rule, only to be obtained where fu nction has been restored.

6. The replacement should be as nearly as possible in terms of the tissue lost, i.e., bone for bon e, carti lage for cart i lage , fat for fat, etc.

7 . The gain of the skin in Raps has to be written off agai nst th e loss which occurs when the bed from w h ich it was rai sed is c losed.

8. Th e factors necessary for the prod uction of the opti m u m scar are: (a ) asepsis; (b) avoidance of tension on the opposi n g sutu res; (c) perfect a pposition of th e skin edges; (d ) an often un known personal factor in the pati ent; and (e) early removal of the sutures (th e opposing sutures on the th ird and fou rt h day, retai n ing sutures left u nt i l their fu nction i s fu l fi l led ).

9. The closest watch i s maintained d u ri n g the first 48 hours u pon the s ite of the opeation.

I 0. Ti me is the plastic su rgeon's greatest al ly and also h is most trenchant crit ic.*

After World War II, Ralph Millard (Fig. 1-9) visited Gillies and in 1950 published a paper entitled "Plastic Peregrinations" in which he outlined what he called the Ten Commandments of Gillies as leaned at the feet of the master.20 Some of the Commandments are the same as those Gillies out-

*From Gi l l ies, H. D.: Plastic su rgery of the face, London , 1920. Oxford Univcrsit}" Press, pp. 3-34.

lined in 1920. Following are additional principles of Gillies20:

I. Plastic su rgery i s a constant batt l e between beauty and blood su pply.

2. Make a plan and a patten for th i s plan. 3. H ave a l i fe boat; that i s, have a reserve plan. 4. A good style wi l l get you thwu gh , when w ithout

i t you would fai l . 5 . Treat t h e primary defect i rst, n o t l etting con

cen for the secondary defect endanger the f ina l resu lt, but borrow from Peter to pay Pau l only when Peter can a fford i t .

6 . Never throw anything away. 7. Never let routi ne method become you r master;

[ that is, fi t the operation to the patient and not vice versa ] .

8. N ever do today what can honorably be put off unt i l tomorrow-when i n doubt, don't.*

As a result of the collaboration of Millard with Gillies, the Principles and Art of Plastic Surgey appeared in 1957.18 The second chapter of the book was devoted to principles of plastic surgery. The principles were a combination of those outlined by Gillies in 1920, those ascribed to him by Millard in 1950, with some additional principles. These additional principles are as important as their predecessors: irst, whereas in 1920 Gillies stated that it was necessary to obtain a history, by 1957 "Observation is the basis of surgical diagnosis."18 Similarly, Gillies and Millard elaborated on what they meant by a good style. They said that the hallmark of the style was "dexterity and gentleness," and they gave the easily remembered aphorism, "Do not lean on the patient or lift him by the stitches!" Another principle, "Do something positive," would appear to be the basis of Millard's rotation advancement principle. As Gillies and Millard wrote, "When a lacerated lip is a jigsaw puzzle, look for landmarks, and if you can ind two bits that deinitely it, put them together-at least you will have made the irst move." Consultation with other specialists was also emphasized. They said, "In planning, two heads are better than one. In execution, gain cooperation of the regional expert." Another important principle was "Speed in surgery consists of not doing the same thing twice." And, as the 1957 book itself shows, "Only by late follow-up can methods be effectively evaluated," a principle that should be remembered whenever reading about a new plastic procedure. The importance attached to these principles is best

*From Mi l lard, D. R.: Plastic peregri nations, Plast. Reconstr. Su rg. 5 : 2 6, 1950.

12 Bsic principles

Fig. 1- 1 0. Gas pare Tagliacozzi (bookplate of Dr. J erome P. Webster). (Cou rtesy Jerome P. Webster, M.D.)

seen by a statement made by Gillies and Millard: "The various principles apply not merely to plastic problems, but have a basis applicable in a more general way to a philosophy of life."* THE PURPOSE OF PLASTIC SURGERY

We have discussed the principles of the history and practice of plastic surgery, but what is the purpose of plastic surgery? Is the goal the satisfaction of the patient with the end result, or is it the satisfaction of the surgeon in accomplishing the ends to the result? Is it the gain that the patient achieves in interpersonal relationships, or is it the gain that the surgeon achieves in his bank account? As a mere student of plastic surgery it would be presumptuous for me to pontiicate on the purpose of plastic surgery. Surgeons much older and wiser than I have offered their conceptions of the purpose of plastic surgery, and I should like to share their thoughts with you.

Gas pare Tagliacozzi (Fig. 1-1 0), Professor of Medicine at the University of Bologna in the sixteenth century, who is considered to be the father of plastic surgery because of his publication of the irst textbook of plastic surgery, offered a purpose of plastic surgery that seems to be as relevant today as it was when it was published in 1597. Tagliacozzi26 said:

We bring back, refash ion , and restore to wholeness those features which nature gave bu t chance destroyed , not that they may charm the eye but that they may be an advan tage to the l iv ing sou l , not as a means of artiice, bu t as an a l leviation of i l lness, not as become charta-

* From Gil l ies, H. D., and Mi l lard, D. R. : Principles and art of plastic su rgery, Boston, I 957, Littl e. Brown & Co.

Fig. 1 - 1 1. B renthurst Cl inic tapestry. (Cou rtesy Mr. Jack Penn.)

The principles and purpose of plastic surgey-past and present 13

tans , but as become the good ph ysicians and fol lowers of the great Hippocrates. For a l though the original beauty of the face is , indeed , restored , this i s only accidenta l , and the end for w hich the ph ysician is working is that the featu res should fu li l l their ofices according to nature's degree. *

Tagliacozzi was given to the use of lowery phrases that characterizes much scholarly writing of the sixteenth century. A more succinct delineation of the purpose of plastic surgery was given by a general surgeon of the twentieth century, William Mayo.24 His statement of the purpose of plastic surgery is inscribed in a tapestry at the Brenthurst Clinic in South Africa.23 This tapestry depicts the history of plastic surgery beginning with the ancient Egyptians who treated facial fractures and the Indian castes who reconstructed noses from forehead laps as described in the Cowasjee broadside. The tapestry depicts Tagliacozzi, as well as the modern plastic surgeon and his patient. Just as Millard described Gillies' principles as being the Ten Commandments of plastic surgery, so do the words that Mayo used to describe the purpose of plastic surgery represent a commandment in themselves for the purpose of plastic surgery and are an appropriate point for closing. Mayo said, "It is the divine right of man to look human" (Fig. 1- 1 1).

* From Tagliacozzi , G. : De cu rtorum chirurgia per i nsit ionem. Translated in Grudi , M. T. , and Webster, J . P. : Life and Times of Gaspare Tagliacozz i , New York, 1 950, Herbert Reich ner, p. 33 1 .

REFERENCES I . Anonymous: I nsti t u t Academie des Sciences, Rhino

plastie , J . U n iv. H ebdomadaire 5 :4 1 7 , 1 83 1 . 2 . Anonymous: M S cata logue of Sir Ast ley Cooper's

preparations, H u n terian M u se u m , Royal College of Surgeons, London.

3. Anonymou s : Rhinoplast ic operation , Med. Chir. Rev. 1 7 : 1 72 , 1 83 2 .

4 . Bai ley, H . : Case of reu n ion of t h e first phalanx of the middle i nger com m u n icated in a let ter to Dr. Wi l l iam Balfour, Edin. Med. Su rg. J . 1 1 :3 1 7 , 1 8 1 5.

5. Balfour, W . : Two cases, wi th observations, demonstrative of the powers of natu re to reu nite parts wh ich have been , by accident , total ly separated from the animal system , Edin . Med. Su rg. J. 1 0 : 42 1 , 1 8 1 4 .

6 . Bal fou r, W. : O n the first not ice o f a re-u nion a fter ent ire separat ion of part s, London Med. Phys. J. 37 :472 , 1 8 1 7 .

7 . B landin , P. : De l 'autoplast ie , Paris , I 836, U rtubie.

8. Carpue, J . C. : An account of two successfu l operations for restoring a lost nose wi th the integu ments of the forehead in the cases of two oficers of H i s Majesty's army, i n which are i ncl uded historical and physiological remarks on the nasal operation including descriptions of the I ndian and I ta l ian methods, London , 1 8 1 6 , Longman, H u rst, Rees, Orme, and B row n.

9. Carpue, J . C. : Geschichte zweier gelungen Faile wo der Verlust der N ase, Ber li n , I 8 I 7, Realsch u lbuchhandlu ng.

1 0 . Darwi n , F. : Francis Galton 1 822- 1 9 1 1 , Eug. Rev. 6 :9 , 1 9 1 4 .

I I . Dunham , T. : Method for obtai n ing a skin flap from the sca lp and a permanent bu ried vascu lar pedicle for covering defects of the face, Ann. Su rg. 1 7 :677 , 1 893.

1 2. Duplay, S. , and Reclus , P. : Traite de chirurgie, vol. 4 , Paris , I 89 I , G. Masson.

1 3 . Fioravant i , L. : I I tesoro della v i ta h u mana, Venice, I 570, Sessa.

1 4. Fresh water, M. F. : More about B. L. , M r. Lucas, and M r. Carpue. Plast. Recon str. Su rg. 49:78 , 1 972 .

1 5 . Freshwater, M. F. : George David Pollock and the development of skin graft ing, M . D. thesis, Yale U n iversity, N ew H aven , Con n . , I 972.

1 6. Fresh water, M. F. : Pre- Baronian t i ssue transfer, Conn. Med. 40:6 1 3 , 1 976.

I 7. Gi l l ies , H. D. : Plastic su rgery of the face, London , 1 920, Oxford U n iversity Press.

1 8. Gi l l ies, H. D., and M i l lard, D. R. : Principles and art of plastic su rgery , Boston , 1 95 7 , Little, B rown & Co.

1 9. Litt ler, J. W. : Neurovascu lar pedicle transfer of t issue in reconstructive su rgery of the hand, J. Bone Joint Su rg. 384:9 1 5 , 1 956.

20. M i l lard, D. R. : Plastic peregrinations, Plast. Reconstr. Su rg. 5 :26 , I 950.

2 I . Monks, G. H . : Restoration of a lower eyelid by a new method , Boston Med. Surg. J. 1 39:385, 1 898.

22 . Owen , R. : On the archetype and homologies of the vertebrate skeleto n , London , 1 848, J . Van Voorst.

23. Pen n , J . : B ren th u rst Cl in ic tapestry, B r. J . Plast. Surg. 20: 1 04 , 1 967 .

24 . Pen n , J . : Personal com m u n ication , J u ly , I 970. 25. Reisinger, F. : Die Keratoplasti k , Bayeri sche Ann.

1 :207, 1 824. 26. Tagl iacozz i , G. : De curtorum chirurgia per insi

t ionem. Translated in Gnudi , M . T. , and Webster, J. P. : Life and times of Gaspare Tagliacozzi , New York, I 950, Herbert Reichner.

2 7 . Tubiana, R. , and Du parc, J . : Operation pall iative pour paralysie sensitive a Ia mai n , Mem. Acad. Surg. 85:666, I 959.

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