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Constance M. Chen and Robert J. Allen


Plastic and reconstructive surgery is a field that relies upon basic principles to
restore form and function to the human body. Whether it is a gunshot wound to the
face, a congenital hand deformity, or a malformed breast, plastic surgeons must be
adept at adapting a fundamental knowledge of human anatomy and physiology to
create ingenious solutions to ever-changing challenges. Unlike techniques which
must be modified with each new advance in medical technology, the use of prin-
ciples makes it possible for the plastic surgeon to address problems as varied as the
infinite diversity of the human species. Rote memorization of operative steps and
mathematical formulas are insufficient. The reconstruction of the human body de-
pends upon the ability to devise creative solutions based on core principles. Over
the years, numerous efforts have been made to categorize these principles. Despite
changes in technique, the fundamental principles of plastic and reconstructive sur-
gery 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 is superfluous.” Whether ap-
plied to the excision of redundant tissue or the complete amputation of a surplus
structure such as a digit or a supernumerary nipple, this first principle empha-
sized the need to eliminate that which served no purpose. The second principle
was “to restore to their places things which are displaced.” Whether applied to a
congenital deformity, such as a cleft lip, or an acquired deformity, as in trauma,
this principle required recognition of normal 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 required the
ability to conceptualize a hypothetical norm. Indeed, a given defect could often
be determined accurately only after distorted tissue was returned to its normal
shape. This was true whether applied to a congenital defect, such as syndactyly, or
an acquired defect, such as a burn contracture. Finally, the fifth principle, “to
supply the defects of nature,” also required the ability 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



Practical Plastic Surgery

that “plastic surgery is 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 the most widely recognized efforts to outline the principles of
reconstructive surgery. In 1950, Millard codified rules learned from Gillies and pub-
lished them as the “ten commandments” of plastic surgery (Table 10.1). Shortly
thereafter, the pair expanded these ideas to 16 principles that would apply not only
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.

Preparational Principles

Millard’s first 12 principles fell under the framework of “Preparational
Principles”-that is, principles to keep in mind before making the opening incision.
The first principle was to “correct the order of priorities.” Applied broadly, this
could mean emphasizing integrity and ethics; it could mean prioritizing function
over form; and it could also mean performing a blepharoplasty before a facelift since
the latter could affect the former but not vice versa. The bottom line was that whether
in life or in a specific procedure, each part needed to be considered in the context of
the whole.

The second principle was that “aptitude should determine specialization,” mean-
ing that the plastic surgeon should play to strengths when deciding whether to focus
on reconstructive surgery, cosmetic surgery, microvascular surgery, craniofacial sur-
gery, head and neck oncology, hand surgery, burn physiology or laboratory research.
Millard emphasized that a person who initially appeared inept in one area could
later progress to excel above all others in the same area. Using himself as an example,
Millard revealed that he took an aptitude test early in his career that determined that
he would be well-suited to writing and possibly medicine, but completely unsuited
for surgery due to a perceived inability to visualize objects in three dimensions.
Despite this, he went on to become one of the most accomplished plastic surgeons
in history, known especially for the three-dimensional rotation-advancement flap
that is the standard of care for cleft lip repair today.

Table 10.1.Gillies’ ten commandments of plastic surgery

1.Thou shalt make a plan.
2.Thou shalt have a style.
3.Honor that which is normal and return it to normal position.
4.Thou shalt not throw away a living thing.
5.Thou shalt not bear false witness against thy defect.
6.Thou shalt treat thy primary defect before worrying about the secondary one.
7.Thou shalt provide thyself with a lifeboat.
8.Thou shalt not do today what thou canst put off until tomorrow.
9.Thou shalt not have a routine.
10.Thou shalt not covet thy neighbor’s plastic unit, handmaidens, forehead
flaps, Thiersch grafts, cartilage nor anything that is thy neighbor’s.



Principles of Reconstructive Surgery

The third principle was to “mobilize auxiliary capabilities.” That is to say, the
plastic surgeon should incorporate individual talents to develop a “personal style
with individual flair.” Advised to develop one primary capability and several second-
ary talents such as sculpture, music, writing or painting, the ideal plastic surgeon
would be multi-talented for maximal depth and versatility in the operating room.
The fourth principle was to “acknowledge your limitations so as to do no harm,” a
self-evident principle that spoke to the temptation to persevere on a case with endless
complications. Instead, the successful surgeon should know when to stop. The flip
side of this was the fifth principle, which was to “extend your abilities to do the most
good.” This spoke to the moral obligation to use plastic surgical training to alleviate
human suffering, that is, to reconstruct mutilated or severely deformed patients in-
stead of limiting one’s practice to purely aesthetic procedures. The sixth principle
was to “seek insight into the patient’s true desires.” Delving into the psyche, this
principle directed the plastic surgeon to decipher a patient’s actual problems instead
of merely taking the stated problem at face value to preempt patient disappoint-
ment, improve public relations and prevent postoperative legal complications.
The seventh principle was to “have a goal and a dream.” In plastic surgery, this
principle shifted depending on whether a procedure was primarily cosmetic, in which
the goal would be to surpass normal, or primarily reconstructive, in which the goal
would be to attain normal. Either way, the plastic surgeon should have a target in
mind before beginning an operation. The eighth principle was to “know the ideal
beautiful normal.” While this ideal beautiful normal could vary among different
ethnic backgrounds, it was important for the plastic surgeon to be able to define it
in order to attain pleasing aesthetic proportions and visual harmony.
The ninth principle was to “be familiar with the literature.” Knowing what had
already been described assisted a surgeon in discriminating between procedures that
would and would not be successful; it also gave the surgeon access to a collective
bank of experience that allowed extension beyond what one person could accrue in
a lifetime. The tenth principle, to “keep an accurate record,” was like the sixth prin-
ciple in that its underlying purpose was both to further patient care and provide
legal protection for the surgeon. In addition, since memory was inherently unreli-
able, accurate written and photographic records provided baseline references that
allowed the plastic surgeon to coordinate multi-staged procedures to achieve a suc-
cessful final result.

The eleventh principle was to “attend to physical condition and comfort of po-
sition.” Often overlooked by single-minded surgeons, the basis of this principle was
the belief that the optimal surgical performance depended upon good physical con-
dition and a comfortable working position for the surgeon. Finally, the twelfth prin-
ciple, “do not underestimate the enemy,” acknowledged that peril lay behind every
procedure. Thus, whether the enemy was hypertrophic scar formation or inadequate
vascular supply, it was never possible to be overly vigilant in preventing surgical

Executional Principles

The second category of principles addressed the wielding of the blade. The thir-
teenth principle, “diagnose before treating,” emphasized that observation was the
basis of surgical diagnosis. The plastic surgeon must use all senses—particularly
visual and tactile cues—to accurately determine a problem before proceeding with
an operation. The fourteenth principle was reminiscent of Paré, in that it advised



Practical Plastic Surgery

the plastic surgeon to “return what is normal to normal position and retain it there.”
As previously mentioned, displacement of structures could be due to failure in nor-
mal embryonic development or as a direct result of trauma, ablation, scar contrac-
tion, or even the aging process, but correction required the ability to recognize the
norm in order to restore displaced parts to their correct place.
The fifteenth principle stated that “tissue losses should be replaced in kind.”
More specifically, when attempting reconstruction of lost body parts, bone should
be replaced with bone, muscle with muscle and glabrous skin with glabrous skin. If
exact replacement was impossible, then a similar substitute should be made, such as
a beard with scalp, thin skin for an eyelid, thick skin for the sole of a foot, and a
prosthesis for an eye. The idea was that replacing like with like would give the most
natural outcome. The sixteenth principle advised the plastic surgeon to “reconstruct
by units.” By basing reconstruction on unit borders demarcated by creases, margins,
angles and hairlines, surgical scars could often be concealed by the meeting of light
and shadow.

The seventeenth principle was to “make a plan, a pattern and a second plan
(lifeboat).” By visualizing an entire operation from beginning to end, the plastic
surgeon could anticipate possible difficulties and then proceed to devise a secondary
plan for use should the primary plan fail. The eighteenth principle was to “invoke a
Scot’s economy.” This involved thrift in surgery, in which no tissue was ever dis-
carded until it was certain that it was no longer needed. A corollary of this was to
discard the useless, as once a piece of tissue was determined to have no further value
it should be removed—but refrigerated storage was advised even then in case the
tissue could be used later.
The nineteenth principle was to “use Robin Hood’s tissue apportionment.” That
is, Robin Hood would steal from the rich to give to the poor. Likewise, this prin-
ciple advised using excess tissue to make up for areas with tissue deficits by rotating,
transposing, or transplanting expendable tissue flaps to areas in need. The corollary
to this was the twentieth principle, to “consider the secondary donor site.” That is,
while reconstructing deficient areas with tissue taken from areas that were more
ample, the resulting secondary defect must also be considered to make sure that its
sacrifice was not too deforming. The twenty-first principle was to “learn to control
tension.” In opening, tension usually facilitated a clean cut with the scalpel; in clo-
sure, tension could lead to tissue necrosis or excess scarring; in flap design, skin
tension lines could be identified and used to camouflage scars. The twenty-second
principle was to “perfect your craftsmanship.” For the plastic surgeon, “good” sug-
gested mediocrity, and nothing short of perfection was acceptable. The twenty-third
and final executional principle was “when in doubt, don’t!” Doubt should function
as a deterrent, and if a solution to a problem left seeds of doubt, it was better to
develop a better idea.

Innovational Principles

The third category of principles governed the generation of new concepts in
plastic surgery. The twenty-fourth principle was to “follow up with a critical eye.”
That is, it was important to follow patients postoperatively over time to critically
evaluate results, as regular review of one’s handiwork was the best way to spur ad-
vancement and improvement of surgical procedures. Likewise, the twenty-fifth prin-
ciple, to “avoid the rut of routine,” exhorted surgeons to shun mindless and tenacious
clinging to unthinking rituals. Again, by thinking outside the box, the plastic sur-
geon could make the advance to the next level of innovation and development. The



Principles of Reconstructive Surgery

twenty-sixth principle, “imagination sparks innovation,” was the “breakthrough” or
problem-solving principle that encouraged free-spirited thinking and creativity.
The twenty-seventh principle, “think while down and turn a setback into a vic-
tory,” was labeled the “prince of principles” by Millard. It admonished the surgeon
not to panic or despair, or compound error when faced with possible defeat. In-
stead, the surgeon should keep cool while determining the cause of loss, expend no
energy in worrying about a compromised position, and make certain not to repeat
the same mistake while thinking one’s way to recovery. Finally, the twenty-eighth
principle was to “research basic truths by laboratory experimentation.” By testing
even minor theories in the laboratory, the surgeon could discover answers to plastic
surgical questions in a controlled setting.

Contributional Principles

The fourth set of principles governed ways to contribute to the field of plastic
surgery. The twenty-ninth principle was to “gain access to other specialties’ problems.”
By consulting with physicians or surgeons from other specialties, it could be possible
to learn management of common complications that would both benefit patients as
well as broaden the base of plastic surgery. The thirtieth principle was that “teaching
our specialty is its best legacy.” The implication was that the best way to extend plastic
surgery was to transmit knowledge via lectures, books, symposiums and personal ex-
periences to ensuing generations. The thirty-first principle was to “participate in re-
constructive missions.” Moreover, the ideal method to conduct such missions was to
lend specialists not just to operate, but to teach people in underdeveloped countries
how to perform the operations and manage all the postoperative care themselves.

Inspirational Principles

The final set of principles attempted to prod the plastic surgeon to strive for
perfection. Toward this end, the thirty-second principle was to “go for broke!” That
is, the plastic surgeon should use every means possible to overcome obstacles, strive
for the very best, and seek perfection. The thirty-third and last principle was to
“think principles until they become instinctively automatic in your modus oper-
andi.” By incorporating principles constantly and consistently into plastic surgical
practice, it would become second nature to avoid rote memorization of techniques
and instead stimulate the imagination to engage in innovative problem solving.

The Reconstructive Ladder

The traditional approach to the reconstruction of a variety of defects is based on
the concept of the reconstructive ladder (Fig. 10.1). The basic notion is that one
should use the simplest approach to solving a reconstructive problem, before ad-
vancing up the ladder to a more complex technique. Consequently, if the procedure
fails, one can climb to the next level of complexity. For example, a lower extremity
venous stasis ulcer should be treated by dressing changes alone or by a split-thickness
skin graft if these are applicable. A more complex reconstruction with a free flap
should be reserved as a last resort if all simpler options have been ruled out or have
failed. More recently, however, experienced reconstructive surgeons are beginning
to realize that certain problems are not amenable to simple solutions. In select cases,
bypassing the lower rungs of the reconstructive ladder and proceeding directly to
microvascular free tissue transfer is the optimal approach. A good example of this is
post-mastectomy breast reconstruction. For many surgeons, the free TRAM or DIEP
flaps have become the standard of care.



Practical Plastic Surgery

Pearls and Pitfalls

Plastic surgery takes passion, determination and sacrifice. As plastic surgeons, we
would like to create perfection. Yet techniques and procedures are always evolving,
so the operative process must be based upon principles. Without a commitment to
perfection, a concept of what beauty is, and what the end result will be ahead of
time, the surgeon is lost. Poets can be our role models, because poets are creative and
can help show us how to get going with the creative process. Ultimately, however,
plastic surgery involves sacrifice, focus, determination and, above all, will power.
When these qualities are combined, the plastic surgeon is able to elevate the work
that is performed. A person who is able to go to work and create something close to
perfection, striving for perfection, will lead a very satisfying life. By its very nature,
then, plastic surgery gives us the opportunity to enjoy that ideal life.

Suggested Reading

1.Chase RA. Belabouring a principle, milestones in modern plastic surgery. Ann Plast
Surg 1983; 11:255-60.
2.Gillies HD, Millard Jr DR. The Principles and art of plastic surgery. 1st ed. Boston:
Little, Brown and Co., 1957.
3.Millard Jr DR. Plastic Peregrinations. Plast Reconstr Surg 1950; 5:26-53.
4.Millard Jr DR. Principlization of plastic surgery. 1st ed. Boston, Toronto: Little Brown
and Co., 1986.
5.Rana RE, Puri VA, Baliarsing AS. Principles of plastic surgery revisited. Indian J Plast
Surg 2004; 37:124-125.

Figure 10.1. The reconstructive ladder.

Chapter 11

Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience.

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