New Faces

"Plastic surgery" (or the reconstruction of physiognomies for either utilitarian or aesthetic reasons) is no mystery, and is practiced by many competent surgeons in every large city, says Dr. Morris Fishbein, associate editor of the Journal of the American Medical Association.* Dr. Fishbein's discussion is of interest in view of the recent establishment of the International Clinic of Plastic Surgery at St. Andrew's Hospital, London, where some marvelous work of this nature has been done. Facial surgery is attracting wide attention in America because of the activities of Dr. Henry J. Shireson, Chicago surgeon who reconstructed the nose of Fanny Brice, vaudeville actress, but who was subsequently dubbed "nose quack" and was "chased out of New York" by the Daily News (TIME, Oct. 29).

Plastic surgery, largely an outgrowth of the Great War, reached probably its greatest efficiency in American army hospitals. Pioneers on the other side, however, were Major H. D. Gilles, at the Queen's Hospital, Sidcup, who is now in charge at St. Andrew's, and the French surgeon Delageniere, at Val-de-Grace, Paris.

It was made necessary by the unusual number of jaw fractures and face injuries which occurred in the early intensive trench warfare. Lieutenant Colonel Vilray P. Blair, St. Louis surgeon, noted that few men were trained to treat such injuries, and organized the "Maxillo-IFacial Service" in the U. S. Medical Corps, consisting of teams or units, each composed of a surgeon, an assistant and a dentist. Special schools were organized, men were sent into the French and British hospitals for observation, and eventually a maxillofacial team was assigned to each base hospital center. Much of the success of such work depends upon the dentistry, as the making of splints for jaws is dental work, and perfect coordination between 'dentist and surgeon was essential. The aim of the Army work was not to improve on nature, but simply to attempt to restore lost parts and correct defects due to injuries and deep scars--in short to counteract mutilations in the best possible way. In many War hospitals, women artists were employed to make permanent records of the cases by drawings, watercolors, waxwork and clay modeling.

In civil life, of course, jaw injuries are uncommon, and facial surgery is largely of the plastic type, dealing with the soft parts of skin and tissue. The chief drawback is the slowness of the process. A case may require a dozen operations before its discharge, for these things cannot be done in a single step. The anaesthesia and prevention of infection are of special importance. Much of the early War work was hampered by infection and lack of equipment. In plastic surgery flaps of skin and tissue are frequently moved from one part of the body to take the place of a defect in another. For instance, a strip of flesh will be dissected from the upper arm, leaving one end attached, and the free end grafted in place on the face, maintaining continuous blood supply. After the upper end is healed, and circulation established, the lower end may be cut away, and the flap turned as needed to fill in the defect. New blood vessels grow into it. When finally healed, the extra material is cut away. This simple process thus necessitates at least three separate operations at 'considerable intervals.

Other types of facial operations involve the bony structure and cartilages. Any part of the skeletal system may be repaired by grafts. Wax models are sometimes constructed for patterns. Long noses may be shortened, bony humps in them may be removed, depressions may be filled in in "saddle noses." At Major Gilles' clinic a woman with terrible burns on her face was equipped with a new jaw and eyebrows. A baby with a withered ear was given a good one. Hundreds of applicants, who want their faces reconstructed because of deformities which militate against employment or marriage, have had to be turned away. Formerly, except in armies, only the rich could afford facial surgery, but the St. Andrew's Clinic will extend its services to persons of moderate means. It will be run on a no-profit basis and will give post-graduate courses to surgeons from all over the world. To guard against commercialization, such students must meet the surgical requirements of the Royal College of Surgeons or the American College of Surgeons. In addition to English and French members of the Clinic staff, two Americans, Dr. J. Eastman Sheehan of New York and Dr. Ferris N. Smith of Grand Rapids, Mich., both having extensive War experience, are associated with the movement. Dentists, artists and sculptors will cooperate.

A chief purpose of the International Clinic is to expose quackery and professional "beauty specialists" in this branch of surgery. No honest surgeon will guarantee a perfect result in this delicate work with living tissue, and sensational claims and hopes must be discounted.

*In a review of recent Progress in Medical Science in the December Forum.