Surgery, Plastic and Reconstructive

As early as 1500 BC, surgeons in India used leaves to rebuild the amputated noses of criminals. By the Renaissance, Tagliacozzi devised a flap and graft using the patient’s skin. A hiatus then prevented further development of plastic surgery technologies because of a belief that restoring and remolding was disreputable in that it interfered with the artistry and will of God.

This attitude lasted until after World War I when plastic surgery came of age as an established specialty. The dire need for reconstruction and cosmesis from the mutilating defects of war spurred the research of new technologies.

In 1917, the tubed pedicle flap was devised simultaneously by Sir Harold Gillies (London) and W. Filatov (Ukraine). The graft could now be freed to grow independently. The dermatome, a surgical device that allowed the operator to excise tissue of uniform and predetermined thickness, was invented by Padgett in 1939 and used extensively in plastic surgery.

Wartime morbidity and industrial accidents challenged surgeons to restore circulation to damaged body parts. The first successful reattachment of an arm was reported in 1962 and of a finger in 1968. The 1980s saw the rise of microsurgery where small vessels, muscles, bone, nerves, and veins could be repaired because microscopy allowed adequate visualization for manipulation of tissues without damage to tiny structures. Repair of cleft lip and cleft palate and other congenital anomalies, including the genitalia, were improved with microsurgery.

Chemical and mechanical technology contributed to improved healing through the development of synthetic antibiotics and safer and longer lasting anesthetics. Early antibiotic use hinged on Fleming’s discovery of Penicillium notatum in London (1928), which was followed by tyrothricin (Rene DuBos) and Waksman’s development of streptomycin in 1944.

After World War II, small-breasted Japanese women, emulating the images of American women, underwent breast augmentation surgery using silicone injection. Failure of the procedure resulted in granulomas and silicone migration. This led to the development of a gel prosthesis in 1963 by Cronin and Gerow with a Dacron patch for attachment to the chest wall. A variety of breast implants continued to be used, some with smooth outer envelopes, others with a fuzzy polyurethane shell believed to stimulate tissue retention. Internal materials ranged from dimethylsiloxane nonliquid gel to saline.

One technology used tissue expanders for the gradual introduction of saline over a period of time. The DIEP procedure is a microsurgical approach to breast reconstruction using the patient’s own skin and fat. After mastectomy, a flap is made from abdominal tissue, and after blood flow is established it is transplanted to the chest wall site.

Cosmetic facial surgery gained in acceptance for the general public as the media promoted stars who appeared to defy ageing. The rhinoplasty, originally developed in Europe, gained popularity as second and third generation Jewish and Italian women in the U.S., desirous of assimilation, underwent this surgery. Autogenous graft materials were taken from ear or rib cartilage, septal tissue, and rib or iliac bone. Gore-Tex, a synthetic material, has been used to augment facial soft tissue.

During the last quarter of the twentieth century, tissue expanders and endoscopy (1993) contributed to less operative time and trauma, faster healing, and reduced intraoperative bleeding. ‘‘Facelifts’’ consist of many procedures. Brow and forehead lifts remove wrinkles from the upper face. Endoscopy removes excess skin and fat from around the upper and lower eyelids. Implants of collagen are used to enhance cheekbones. In the 1990s came the startling news that Clostridium botulinum, the same organism known to cause botulism, was being used in cosmetic surgery.

The organism produces two toxins, type A and type B. Tiny amounts of these as Botox are injected into selected small facial muscles to paralyze them so that frowning will not be possible. Some doctors use electromyograms to guide the needle in the procedure. A self-inflating expander that contains salt, which gradually absorbs fluid, was also being researched at the turn of the twenty-first century.

Perhaps the most ubiquitous technology has been the laser, beginning in 1961 for ophthalmology, then introduced to plastic surgery in the 1990s. The original ruby crystal was replaced with argon and then the pulsed-dye laser. In 1995, laser resurfacing using carbon dioxide (CO₂) was introduced. The tremendous use of lasers within the field of plastic surgery has resulted in removal of hemangiomas, tattoos, vascular lesions, and wrinkles. Endoscopic surgery combined with the erbium: yttrium-aluminum-garnet laser is another late-twentieth century technology.

Between 1930 and 1990, chemicals such as resorcinol, salicylic acid, phenol, and trichloracetic acid (TCA) peels were used to smooth skin. Dermabrasion, a mechanical process, was also employed. Dressings, adhesives and masks to aid healing developed with each of these technologies.

Liposuction has been used since the late 1970s. This technique uses a cannula and suction equipment to remove fat from the thorax, abdomen, and extremities. Internal ultrasound is combined with suctioning so the operator can better view tissue planes.

For most of the twentieth century, cutting tools were made from metal and ceramic materials. The latest development is the argon gas torch, which both creates an incision and coagulates the blood to limit bleeding. Technologies that have greatly enhanced the ability to stop capillary bleeding during cosmetic surgery are platelet gel and fibrin glue, which seal wound surfaces and stop bleeding during surgery and the formation of postoperative hematomas.

Superior to commercial products, the patient’s own blood cells can be collected and used to preclude disease transmission and problems of tissue incompatibility. Suture materials developed from silk and gut have been replaced with vicryl and absorbable synthetic materials; needles are preloaded and packaged in sterile containers.

Body fashion, like other cultural phenomena, changes with time, place, and value. It appears that the more the human body is exposed to display, the greater a variety of technologies will develop to mold it into culturally pleasing icons.