Flap Happy?

Many a plastic surgeon thumbing through a handsome, two-volume medical work last week was startled to find, under the unscientific heading, "Oops!", this homely advice: "Once a graft has been cut, it should be folded, wrapped in a damp gauze and put in a safe place until time for its application. Too often in its trip around the theatre it gets thrown in the wastebucket or dropped on the floor. Pick it up. wash it and get on with the job. It happens in the best of clinics!" And, as the kickoff to a chapter entitled "Flap Happy," there are these wry definitions: "A graft is a piece of detached skin which is dead when you put it on and comes to life later. A flap is a partly attached piece of skin which is alive when you put it on and may die later."

Such salty, down-to-earth treatment of an esoteric surgical specialty could have come only from New Zealand-born Sir Harold Delf Gillies, 74, onetime champion golfer, master of the fly rod, amateur painter and undisputed father of modern plastic surgery in Britain. As co-author of The Principles and Art of Plastic Surgery (Little, Brown; $35), he enlisted the University of Miami's David Ralph Millard Jr., 37, a kindred spirit and former pupil. Utterly different from anything else in the field, their work is neither a set text nor a formal reference book, but a remarkable grafting of plastic surgery history and techniques onto a chatty life history of Innovator Gillies (known to colleagues as "Giles"). Its 2,300 illustrations comprise an unprecedented gallery of human faces and limbs deformed from birth, shattered by shot and shell, smashed in accidents, maimed by disease or burned to hideous unrecognizability. Yet his before-and-after sequences end with a happy improvement, and in many cases there is restoration to completely normal appearance.

Breasts, Noses. In special cases, says

"Gillies, the plastic surgeon is well advised to aim short of perfection. "It is important to remember when remaking the nose for a one-eyed lad not to build the bridge so high that he cannot see the motor bus coming from the blind side." This reminds him of the one-eyed Count of Montefeltro (1422-82), who deliberately had part of his nasal bridge removed: "Thus his one good eye peeking through the notch in his nose discouraged friends sitting on his blind side from trying to poison him."

In other matters, Gillies is a perfectionist. He has no use for the cancer surgeon who removes a woman's breast and suggests no replacement. Gillies makes an incision from below the armpit, across the abdomen, around the navel and back again. With the flesh thus released, he constructs a tube pedicle flap,* and as he brings it around to the side of the missing breast, the inside-out navel (concave to convex) takes the place of the nipple. After this surgery, a woman has an abdominal scar but no deformity. In some patients, as a result of an embryonic failure, a breast may be missing, with only a nipple present; in such cases, Surgeon Gillies has built a mound of tissue under and around the nipple. In one case, he notes: "With marriage and pregnancy, the diminutive portion of breast tissue increased greatly and enabled lactation to occur through this new breast."

Pedicle flaps from the arm are sometimes attached to the stump of a partly destroyed nose as the first step in its reconstruction. They are then severed from the arm. This gives the patient a "trunk" several inches long. One man disappeared after this stage of the operation, did not show up again for years. Then he explained: he had made a living in a circus sideshow as "the elephant man." With the flap tailored as planned, the nose looked normal, and he got a new job.

Ears, Eyebrows. Much plastic surgery involves correcting abnormalities about the face. A child may be born with a malformed ear, or no ear. Surgeon Gillies sometimes uses beef cartilage as the base for sculpturing a new ear with flaps of the child's skin, but he prefers to get cartilage from the mother's ear. This can be done without disfiguring her, and as Gillies notes tartly, she can wear her hair low to cover the scar--which her son cannot. Such grafts have lasted 15 years. In one remarkable case, Gillies used part of a woman's ear to repair her nose; he wonders whether she is now hearing through the nose or smelling through her ear.

On nose-bobbing for appearances' sake: "If as the patient comes in the door you can't take your eyes off the huge and distorted nose, then reduction is usually justified." But some people with normal noses have a "nasal complex"; no surgery can help them. "Such patients are usually sent by a psychiatrist. The best thing to do is to send them back; the psychiatrist has taken the easy way out by suggesting surgery to cure a nasal complex."

Some Gillies operations are notable for lively ingenuity: he has reconstructed eyelids, complete with lashes, from the edge of the eyebrow. Others are heroic. He does not flinch from cutting through the bones of the upper jaw so that most of the face is detached from its moorings, then fixing the bones in a new alignment. And some patients are heroic: a woman whose entire lower jaw was removed for cancer in 1939, so that her tongue hung down her neck, has had 27 plastic operations. She has a new lower jaw with a denture, and eats normally. Though now presentable-looking, she would like to give the plastic surgeon a chance to achieve perfection in his art. So, says Gillies: "When I am on my last ride in my little box, she will run alongside, calling in her distorted voice, 'Please, sir, just one more operation before you go.' "

* Invented by Gillies; so-called because the flap, while being grafted into its new position, is left attached to a tubular stalk (pedicle) of tissue and thus well supplied with blood. The pedicle is removed later.

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