By Michele Boyer
- A young man, mutilated as punishment for a petty crime, is brought back to his village where family will care for his wounds. What remains of his nose, tattered shreds, hangs from a mere fiber of cartilage. While his family cleans him up and bandages his wounds, his brother runs to a nearby town to beg the services of Sushruta2,10 (also spelled Susruta and Sushrutha).
- Sushruta, a physician renowned for his ability to reconstruct body parts that had been destroyed through injury, was skilled in the art of rebuilding earlobes and noses, replacing flesh, and reconstructing mutilations many men received as punishment for their transgressions, or injuries sustained in battle. He will, as is hoped, reconstruct the young man’s nose, leaving few scars to indicate the near-deadly encounter that might otherwise have marked the boy as an outcast.
- The year was 600 B.C. Sushruta wrote about his techniques in the Sushruta Samhita1, describing 120 surgical instruments, 300 surgical procedures and 8 categories of human surgery1.The records, written in ancient Sanskrit texts around 500-600 B.C., document the details of the surgical procedures, and the minute attention given the reconstructive surgical techniques, including anesthetic and antibiotic procedures of the day.
- The main source of injury believed to have prompted the need for surgical intervention, both then and now, were the injuries inflicted in battle, and in earlier times those inflicted by the practice of punitive mutilation, including amputations, often of the ear lobes, lips, or nose.
- One early reconstructive procedure is described in “History of Plastic Surgery in India” by R.E. Rana and B.S. Arora as follows2:
“Sushruta has been rightly called the ‘Father of Plastic Surgery’ and ‘Hippocrates’ of the 6th or 7th century BC. He described rhinoplasty for a cut nose as follows:
1) The leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped off part, should be gathered,
2) A patch of living flesh, equal in dimension to the preceding leaf should be sliced off from the region of the cheek.
3) After scarifying the severed nose with a knife, the flesh is swiftly adhered to it.
4) Insert two small pipes in the nostrils to facilitate respiration and to prevent flesh from hanging down.
5) The adhesioned part is dusted with the powders of Pattanga, Yashtimadhukam and Rasanjana pulverized together.
6) The nose should be enveloped in Karpasa cotton and several times sprinkled over with the refined oil of pure sesamum.
7) When the healing is complete and parts have united, remove the excess skin.”
- While it is interesting is that plastic surgery has been practiced for five or six centuries B.C., there is evidence of surgical repair practices being doneas early as 1,600 B.C.by Egyptians8,9, who seem to be the first culture to attempt surgical repairs of facial injuries. Pharonic medicine is documented in papyrus texts, in which one case describes a rhinoplasty. Details such as using packing to stop bleeding, suturing techniques are carefully described. These early surgical efforts were made centuries before Sushruta documented his sophisticated techniques.
- Plastic surgery has come a long way in the3,500+ years since it was first documented, and modern techniques have eliminated most of the pain that one might associate with surgical procedures. According to the American Society of Plastic Surgeons:
- “Despite the popular misconception, the word “plastic” in “plastic surgery” does not mean “artificial,” but is derived from the ancient Greek work “plastikos,” which means to mold or give form. Plastic surgery includes both the reconstructive and aesthetic subspecialties3.”
- Cosmetic surgery, often thought to be another term for plastic surgery, is actually a sub-type of plastic surgery. Plastic Surgery4 is “the surgical specialty that reconstructs areas of the body, which are impaired or damaged because of disease, congenital defect, or a disorder. It includes the sub-specialty of Cosmetic Surgery5, which is done for enhancement of physical appearance rather than to restore normality.”
- Given these definitions, plastic surgery was well documented by Oribasius6,7(c. 320-400) who compiled the known medical techniques of that time in a work called Synagogue Medicae. Although only 25 of the original 70 volumes remain, they preserve many of the ancient surgical techniques used by the Greeks, Romans, and Byzantine surgeons. Volume 42 describes facial reconstruction procedures.
- Aulus Cornelius Celsus8,11, the Roman medical writer who authored De Medicina12, documented techniques similar to those Sushruta described.
- The cultural influence of the middle-ages focused on spiritual rather than temporal improvements, discouraging general interest in reconstructive surgery. Some believed it focused too much on vanity, and the art suffered because the culture encouraged a negative view of reconstructive surgery. Plastic surgery took a blow due to poor hygienic practices as well, resulting in infections, failed surgeries and death from those surgeries that were done.
- However, there were some progressive individuals who attempted reconstruction of a missing nose. Heinrich von Pfolspeuntd’s8 description of this procedure was to take skin from the back of the arm and suturing it in place.
- The early documentation of reconstructive surgical techniques became the foundation for modern plastic surgery when it was passed to Western Europe in the 15th century. But, it wasn’t until around 1800 that interest in reconstructive surgery resumed. In 1791 Chopart8 used a flap taken from the neck to repair a lip. In 1818 plastic surgery pioneer Carl Ferdinand von Graefe13 published Rhinoplastik, a major work describing the use of a skin flap from the arm as a new technique. In 1827Dr. John Peter Mettauer14, America’s first plastic surgeon performed the first cleft palate operation.
- During the later 1800s and early 1900s, explosive weapons caused the most serious war injuries, such as shattered jaws or other facial disfigurements. Physicians were moved to perfect the restorative procedures that would later become the specialties of plastic and cosmetic surgery.
- During this time medicine saw improvements in anesthesia, skin grafts, and, yes, in those times as well as ours, breast implants. By 1891, John Roe offered the first anesthetic during a rhinoplasty surgery. Dr. Roe gained fame as a cosmetic surgeon, performing rhinoplasty surgery to improve the appearance of his patients’ noses for aesthetic improvement, rather than to repair disfigurement.
- In the early years, plastic surgery was not a well-defined specialty, and the only known organization that had any recognition in this area was,in 1921, the American Association of Oral Surgeons.Membership was restricted to physicians who also had dental degrees. Drs. Jacques Maliniac3, an immigrant from Warsaw, Poland, and Gustave Aufricht3, an immigrant from Budapest, Hungary were both excluded from membership despite their key role in promoting acceptance of plastic surgery as a recognized specialty. Both physicians were instrumental in motivating others with interests in plastic surgery to organize.
- By 1931, Dr. Maliniac, along with nine other physicians founded the American Society of Plastic Surgeons (ASPS)15. One primary goal was to gain recognition for their specialty by the American Board of Surgeons who certified physicians in surgical procedures at that time. In the late 1930s The American Board of Surgery established an American Board of Plastic Surgery (ABPS), which provided qualification exams for physicians wanting to practice plastic surgery. In 1941, as medical specialties became more defined, the American Board of Medical Specialties oversaw the ABPS3.
- World War II encouraged many more physicians to learn the art of plastic surgery and refine the procedures, as they were called to treat our wounded soldiers. While Dr. Maliniac concentrated on his private practice, membership in the ASPS grew to about 150 surgeons. In 1948 he founded the Educational Foundation of ASPS. Today it is known as the Plastic Surgery Educational Foundation (PSEF)16.