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The future of plastic surgery
The
Future
of Plastic
ALBERT D. DAVIS, M.D., San Francisco,
Journul
OJ Surgery,
Volume
yy. I;ebruory,
1958
California
genetics and hereditary factors, keloid formntion and many others. While there are many known factors which cause mutations, such as diseases in the earIy months of pregnancy (e.g., rubeIIa), drugs, radiation, etc., there are many unknown factors which influence the norma deveIopment of the embryo. Even so, the present concept of prenata care is to consider pregnancy and chiIdbirth as a natural normal occurrence. Preparation for a norma baby is discussed Iong before childbirth. The possibiIity of an abnormal birth is rareIy discussed and, even if questioned, is gIossed over with theories, unexplained and speculative. It is a we11 known fact [4] that the amniotic fluid present plays an important roIe in the development of the embryo, greatIy increased in anencephalous, stenosis of the duodenum and agenesis of the kidneys. Many other instances of abnormalities may be mentioned which require stern measures for delivery but, in the majority of congenital deformities, childbirth is norma and the obstetrician is hard put to answer a11 the questions of the parents as to the etiology. The diffrcuIty of obtaining evidence in humans by research is obvious. In the majority of tabuIated records of malformations, many abnormaIities of interest to the plastic surgeon are omitted and onIy those deaIing with surviva1 of the infant are Iisted. The frequency of the occurrence of developmenta1 anomaIies is much Iarger than reported. The_centraI nervous system is invoIved more often than any other maIdeveIopment, with cardiac deformities a cIose second, foIlowed by gastrointestinal and genitourinary deficiencies. The pediatrician [4] may be able to treat and care for the genera1 heaIth of these chiIdren but must caI1 upon his surgica1 coIIeagues to correct the malformations. Therefore, there must be a constant increase in the number of men trained for this heId aIone. Furthermore, there must
HE sudden “discovery” of plastic surgery as an entity during World War I (rg141918) did much to pIace it on a very sound basis with other surgical specialties. However, recent historical research [r] shows that operations for repairing defects of the ear lobe with a skin graft and a detailed method of transplanting a skin IIap from the cheek for repairing a nasa1 deformity are described in a text estimated to have been written as early as the sixth century B.C. GeIsus (25 B.C.-50 A.D.) wrote of operations on Iips, noses and ears. The history of pIastic surgery may be traced from this earIy beginning up to the present time. The recent two-voIume work [2] by Sir Harold GiIIies and D. RaIph MiIIard, Jr. describes rather autobiographicahy the search for newer methods for the repair of some of the most fantastic deformities that any group of surgeons has been called upon to correct. The challenge of caring for these war wounds was accepted and men interested in this field were trained so that, at the outbreak of WorId War II, many we11 organized pIastic surgery centers were formed, staffed and made ready to receive the mutiIated victims of that war. With the deveIopment of the tubed pedicIe and other methods, together with the invention of new instruments for taking caIibrated skin grafts and newer methods for safer anesthesia [s], the plastic surgeon now had a choice of procedures to obtain the best cosmetic result. In spite of the experience gained and the foundation of sound basic principles Iaid down by the various Ieaders and pioneers, and in spite of the various short cuts made possibIe by new instruments and the improved methods of anesthesia, there is stiI1 a great void Ieft which handicaps the plastic surgeon and which can be solved only through research. These probIems are most perpIexing in that they concern transpIantation of tissues and organs, mutations due to drugs, diseases, radiation,
T
American
Surgery
312
The Future
of Plastic
be ways and means, through research and experimentation, by which these maIformations might be prevented. The constant factors, which the pregnant mother tolerates well but injure the.fetus, must be sought out; perhaps many of the older theories of arrested development should be discarded and attention turned to wider fields. It has been demonstrated that practically every abnormaIity resulting from genetic action in mammals may be reproduced by artificial means. A combination of genetics factors may cause the an d environmental majority of deveIopmenta1 defects, especiali) in cleft palates. The influence of dietary requirements with insuffIcient riboflavin is well established. This brings the subject of congenital malformations into a somewhat mixed pattern which some believe is purely on a genetic basis and others on the many diverse patterns by which they may originate. The problem thus becomes one in which the pIastic surgeon is involved, and his training for the care of these cases, as well as the many others, becomes the paramount issue in the future. With the advent of nuclear fission and radiation exposure (even if outIawed in war) and their deIayed side efFects which appear many years later, we must be aware of their effects from peacetime use for utility purposes. Most of us remember the terrific facial \vounds resulting from trench warfare during World War I and the well recognized burns of the airmen during the same period. World War II brought early flash burns from Pearl Harbor, followed by hopelessly crippled aviators whose pIanes had been shot down in flames. At the present time many men exposed to radiation of various kinds during WorId War II find themseIves either sterile or giving birth to deformed children. The future of pIastic surgery then resolves itself into not only the surgery per se but also the definite understanding of the causation of the deformities. The unknown factors in homotransplantation need further study and research. A mind to observe and trained to “think furiousIy,” apply knowledge gained from previous training is required if these factors are to be found. Every known failure should bring up the quesSoIutions must be found to tion, “Why?“. probIems presenting stumbling bIocks to SUCcess in transplantation of tissues and even organs, if needed, to sustain life. For man) 3’3
Surgery
years it has been known that successful cxchange of skin grafts can be done in identical twins and, recently, kidney transptantations have been accomplished in identical twins. Transplantation of vessels from cadavers to replace hopeIessly diseased vesseIs in the living has prolonged the lives of many. Cornea1 grafts from the dead have given sight to blind eyes. Preserved cartilage and bone are used in many cases to replace their counterparts lost in accidents, disease and filling defects. Substitution of pIastic materials for tissue transplantation offers a wide range of possibilities, both at present and for the future, until the unknown factors are discovered that will allow free homologous transplantations with absolute assurance of takes. There are many other probIems to be considered, many to be solved. Several questions have come to the attention of those interested in the future of plastic surgery. RecentIy James Barrett Brown of St. Louis wrote a timeIy editorial [y]. It discusses primarily the problem of training younger surgeons in all surgical specialties and compares the present trend of training with the methods used only a few years ago, when a house officer or resident was a full-time man who reaIIy resided in the hospital. Problems of economics, ability, age, devotion to the service of the patient, cooperation and the desire for certification by specialty boards are discussed and the fact is emphasized that there are few short cuts which can be made in an?- training program, yet the training program for plastic surgeons of the future must be soIved. A diffIcuIt question thereby arises as to the limitations of the speciahy. The necessit! of thorough knowledge of the known causative factors of deformities has been stressed; knowledge of pathological conditions has not because it is a basic and fundamental requirement in its fullest sense, The smallest, unsuspected lesion, improperly handled, ma>- mean the life of the patient and every preceptee, resident or assistant shouId be always on the alert for these situations. This is especially true in young chiIdren in whom, for exampIe, a deadly synovioma may be passed off as a simple Iipoma undeserving of notice by the more experienced Can aII of these requirements be surgeon. reached in the training programs now in effect? SurgicaI technic is a necessary part of the picture but, without an understanding of future possibilities and the ambiton to solve these
Davis probIems, the trainees may live to see themseIves reIegated to a greatIy Iimited fieId. Whether or not the training period to meet the ideaIs set forth can be carried out without subsidies or schoIarships sufficient to maintain a reasonabIe economic standard in these days of earIy marriages and raising families poses a question. Whether or not research should come first as an entity or be combined with surgery from the beginning is another problem. Research is an expensive affair, requiring Iarge amounts of space, costly apparatus, a great deal of time and a thorough background in the basic sciences as we11as medicine. Great strides have been made in the Iast quarter of a century and further strides wiI1 be made, perhaps faster than we can visuaIize at present. However, the
fact remains that the pIastic surgeon of the future must be prepared and abIe to meet his coIIeagues in every fieId if he is to take his rightful place among them. REFERENCES 1.
2.
3.
4. 5.
314
T. and WEBSTER, J. P. The Life and Times of Gaspare Tagliacozzi. New York, 1950. Herbert Reichner. GILLIES, H. and MILLARD, D. R., JR. The Principles and Art of Plastic Surgery. Boston, 1957. Little, Brown & Co. MAGIL, I. In: GILLIES, H. and MILLARD, D. R., JR. The PrincipIes and Art of PIastic Surgery, chapt. I, part 3. Boston, 1957. LittIe, Brown-& “Co. _ Conference on congenital malformations. Pediatrics, SuppI. to vol. 19, part 11, no. 4, April, 1957. BROWN, J. B. What is your training program? Surgery, 40: 607-610, 1956.
GNUDI, M.
Future
of Plastic
ALBERT D. DAVIS, M.D., San Francisco,
Journul
OJ Surgery,
Volume
yy. I;ebruory,
1958
California
genetics and hereditary factors, keloid formntion and many others. While there are many known factors which cause mutations, such as diseases in the earIy months of pregnancy (e.g., rubeIIa), drugs, radiation, etc., there are many unknown factors which influence the norma deveIopment of the embryo. Even so, the present concept of prenata care is to consider pregnancy and chiIdbirth as a natural normal occurrence. Preparation for a norma baby is discussed Iong before childbirth. The possibiIity of an abnormal birth is rareIy discussed and, even if questioned, is gIossed over with theories, unexplained and speculative. It is a we11 known fact [4] that the amniotic fluid present plays an important roIe in the development of the embryo, greatIy increased in anencephalous, stenosis of the duodenum and agenesis of the kidneys. Many other instances of abnormalities may be mentioned which require stern measures for delivery but, in the majority of congenital deformities, childbirth is norma and the obstetrician is hard put to answer a11 the questions of the parents as to the etiology. The diffrcuIty of obtaining evidence in humans by research is obvious. In the majority of tabuIated records of malformations, many abnormaIities of interest to the plastic surgeon are omitted and onIy those deaIing with surviva1 of the infant are Iisted. The frequency of the occurrence of developmenta1 anomaIies is much Iarger than reported. The_centraI nervous system is invoIved more often than any other maIdeveIopment, with cardiac deformities a cIose second, foIlowed by gastrointestinal and genitourinary deficiencies. The pediatrician [4] may be able to treat and care for the genera1 heaIth of these chiIdren but must caI1 upon his surgica1 coIIeagues to correct the malformations. Therefore, there must be a constant increase in the number of men trained for this heId aIone. Furthermore, there must
HE sudden “discovery” of plastic surgery as an entity during World War I (rg141918) did much to pIace it on a very sound basis with other surgical specialties. However, recent historical research [r] shows that operations for repairing defects of the ear lobe with a skin graft and a detailed method of transplanting a skin IIap from the cheek for repairing a nasa1 deformity are described in a text estimated to have been written as early as the sixth century B.C. GeIsus (25 B.C.-50 A.D.) wrote of operations on Iips, noses and ears. The history of pIastic surgery may be traced from this earIy beginning up to the present time. The recent two-voIume work [2] by Sir Harold GiIIies and D. RaIph MiIIard, Jr. describes rather autobiographicahy the search for newer methods for the repair of some of the most fantastic deformities that any group of surgeons has been called upon to correct. The challenge of caring for these war wounds was accepted and men interested in this field were trained so that, at the outbreak of WorId War II, many we11 organized pIastic surgery centers were formed, staffed and made ready to receive the mutiIated victims of that war. With the deveIopment of the tubed pedicIe and other methods, together with the invention of new instruments for taking caIibrated skin grafts and newer methods for safer anesthesia [s], the plastic surgeon now had a choice of procedures to obtain the best cosmetic result. In spite of the experience gained and the foundation of sound basic principles Iaid down by the various Ieaders and pioneers, and in spite of the various short cuts made possibIe by new instruments and the improved methods of anesthesia, there is stiI1 a great void Ieft which handicaps the plastic surgeon and which can be solved only through research. These probIems are most perpIexing in that they concern transpIantation of tissues and organs, mutations due to drugs, diseases, radiation,
T
American
Surgery
312
The Future
of Plastic
be ways and means, through research and experimentation, by which these maIformations might be prevented. The constant factors, which the pregnant mother tolerates well but injure the.fetus, must be sought out; perhaps many of the older theories of arrested development should be discarded and attention turned to wider fields. It has been demonstrated that practically every abnormaIity resulting from genetic action in mammals may be reproduced by artificial means. A combination of genetics factors may cause the an d environmental majority of deveIopmenta1 defects, especiali) in cleft palates. The influence of dietary requirements with insuffIcient riboflavin is well established. This brings the subject of congenital malformations into a somewhat mixed pattern which some believe is purely on a genetic basis and others on the many diverse patterns by which they may originate. The problem thus becomes one in which the pIastic surgeon is involved, and his training for the care of these cases, as well as the many others, becomes the paramount issue in the future. With the advent of nuclear fission and radiation exposure (even if outIawed in war) and their deIayed side efFects which appear many years later, we must be aware of their effects from peacetime use for utility purposes. Most of us remember the terrific facial \vounds resulting from trench warfare during World War I and the well recognized burns of the airmen during the same period. World War II brought early flash burns from Pearl Harbor, followed by hopelessly crippled aviators whose pIanes had been shot down in flames. At the present time many men exposed to radiation of various kinds during WorId War II find themseIves either sterile or giving birth to deformed children. The future of pIastic surgery then resolves itself into not only the surgery per se but also the definite understanding of the causation of the deformities. The unknown factors in homotransplantation need further study and research. A mind to observe and trained to “think furiousIy,” apply knowledge gained from previous training is required if these factors are to be found. Every known failure should bring up the quesSoIutions must be found to tion, “Why?“. probIems presenting stumbling bIocks to SUCcess in transplantation of tissues and even organs, if needed, to sustain life. For man) 3’3
Surgery
years it has been known that successful cxchange of skin grafts can be done in identical twins and, recently, kidney transptantations have been accomplished in identical twins. Transplantation of vessels from cadavers to replace hopeIessly diseased vesseIs in the living has prolonged the lives of many. Cornea1 grafts from the dead have given sight to blind eyes. Preserved cartilage and bone are used in many cases to replace their counterparts lost in accidents, disease and filling defects. Substitution of pIastic materials for tissue transplantation offers a wide range of possibilities, both at present and for the future, until the unknown factors are discovered that will allow free homologous transplantations with absolute assurance of takes. There are many other probIems to be considered, many to be solved. Several questions have come to the attention of those interested in the future of plastic surgery. RecentIy James Barrett Brown of St. Louis wrote a timeIy editorial [y]. It discusses primarily the problem of training younger surgeons in all surgical specialties and compares the present trend of training with the methods used only a few years ago, when a house officer or resident was a full-time man who reaIIy resided in the hospital. Problems of economics, ability, age, devotion to the service of the patient, cooperation and the desire for certification by specialty boards are discussed and the fact is emphasized that there are few short cuts which can be made in an?- training program, yet the training program for plastic surgeons of the future must be soIved. A diffIcuIt question thereby arises as to the limitations of the speciahy. The necessit! of thorough knowledge of the known causative factors of deformities has been stressed; knowledge of pathological conditions has not because it is a basic and fundamental requirement in its fullest sense, The smallest, unsuspected lesion, improperly handled, ma>- mean the life of the patient and every preceptee, resident or assistant shouId be always on the alert for these situations. This is especially true in young chiIdren in whom, for exampIe, a deadly synovioma may be passed off as a simple Iipoma undeserving of notice by the more experienced Can aII of these requirements be surgeon. reached in the training programs now in effect? SurgicaI technic is a necessary part of the picture but, without an understanding of future possibilities and the ambiton to solve these
Davis probIems, the trainees may live to see themseIves reIegated to a greatIy Iimited fieId. Whether or not the training period to meet the ideaIs set forth can be carried out without subsidies or schoIarships sufficient to maintain a reasonabIe economic standard in these days of earIy marriages and raising families poses a question. Whether or not research should come first as an entity or be combined with surgery from the beginning is another problem. Research is an expensive affair, requiring Iarge amounts of space, costly apparatus, a great deal of time and a thorough background in the basic sciences as we11as medicine. Great strides have been made in the Iast quarter of a century and further strides wiI1 be made, perhaps faster than we can visuaIize at present. However, the
fact remains that the pIastic surgeon of the future must be prepared and abIe to meet his coIIeagues in every fieId if he is to take his rightful place among them. REFERENCES 1.
2.
3.
4. 5.
314
T. and WEBSTER, J. P. The Life and Times of Gaspare Tagliacozzi. New York, 1950. Herbert Reichner. GILLIES, H. and MILLARD, D. R., JR. The Principles and Art of Plastic Surgery. Boston, 1957. Little, Brown & Co. MAGIL, I. In: GILLIES, H. and MILLARD, D. R., JR. The PrincipIes and Art of PIastic Surgery, chapt. I, part 3. Boston, 1957. LittIe, Brown-& “Co. _ Conference on congenital malformations. Pediatrics, SuppI. to vol. 19, part 11, no. 4, April, 1957. BROWN, J. B. What is your training program? Surgery, 40: 607-610, 1956.
GNUDI, M.