Principles of plastic and reconstructive surgery and how they are applied


Plastic and reconstructive surgery is a field that relies upon fundamental principles to restore form and function to the human body. Regardless of whether it is a gunshot wound to the face, a congenital hand deformity, or a malformed breast, plastic surgeons should be adept at adapting a fundamental understanding of human anatomy and physiology to produce ingenious solutions to ever-changing challenges.

Unlike techniques which should be modified with each new advance in medical technology, the use of principles makes it feasible for the plastic surgeon to address problems as varied as the infinite diversity of the human species.

Rote memorization of operative actions and mathematical formulas are insufficient. The reconstruction of the human body depends upon the capability to devise creative solutions based on core principles. Over the years, numerous efforts have been made to categorize these principles. Despite changes in method, the fundamental principles of plastic and reconstructive surgery have withstood the test of time.

Ambrose Paré

The earliest principles of reconstructive surgery may be attributed to the French surgeon, Ambrose Paré, who in 1564 published five basic principles of plastic surgery.

The first principle was "to take away what's superfluous." Regardless of whether applied to the excision of redundant tissue or the complete amputation of a surplus structure like a digit or a supernumerary nipple, this first principle emphasized the need to eliminate that which served no purpose

The second principle was "to restore to their locations things which are displaced." Whether applied to a congenital deformity, like a cleft lip, or an acquired deformity, as in trauma, this principle needed recognition of regular parts and diagnosis of the abnormal position.

Likewise, the third and fourth principles, "to separate tissues which are joined together," and "to join those tissues which are separate," also needed the ability to conceptualize a hypothetical norm. Indeed, a given defect could frequently be determined accurately only after distorted tissue was returned to its regular shape.

This was accurate whether applied to a congenital defect, like syndactyly, or an acquired defect, such as a burn contracture. Finally, the fifth principle, "to supply the defects of nature," also required the capability to visualize restoration to a normal state.

Modern Plastic Surgery: Gillies and Millard

Building upon these early ideas, Sir Harold Gillies and D. Ralph Millard took the principles of Paré to the next level. Recognizing that the remodeling of human tissue was different from clay, Gillies and Millard took as their founding principle that "plastic surgery is really a constant battle between blood supply and beauty." That is to say, the reshaping of human structures demanded that its vitality as living tissue be respected.

Drawing upon the wisdom of his mentor, Sir Harold Gillies, Millard produced one of probably the most widely recognized efforts to outline the principles of reconstructive surgery. In 1950, Millard codified rules learned from Gillies and published them as the "ten commandments" of plastic surgery. Shortly thereafter, the pair expanded these ideas to 16 principles that would apply not just to plastic surgery problems but also to a philosophy of life in general.

Millard went on to develop the concept of principles still further in his classic tome, Principalization of Plastic Surgery. Divided into four broad sections, this work offered 33 commonsense rules to help plastic surgeons fashion answers to a variety of surgical problems.

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