Trauma, War, and Wound Healing
Until World War I, most battle injuries were caused by small firearms or sword cuts. Facial injuries were often of little concern to survivors, who were deemed lucky enough to have escaped with their lives. Weapons utilized during World War I, such as heavy artillery and machine guns, created severe injuries on a scale never witnessed before. The circumstances of trench warfare, with men peering over parapets, caused a dramatic rise in the number of facial injuries sustained by soldiers. Shells filled with shrapnel were to blame for many of these facial and head wounds, as they were specifically designed to cause maximum damage. Hot flying metal could tear through flesh to create twisted, ragged wounds or even rip faces off entirely. Facial injuries, although very devasting, were not often as fatal as were the wounds to the chest or head. These facial injuries were not easily treated on the front line. Surgeons would sometimes stitch together a jagged wound without considering the amount of skin that had been lost, and even though the scars would heal, the skin would be contracted, pulling the face into a hideous grimace. Jaw injuries could also leave men unable to eat or drink. Some men had to be nursed sitting up to stop them from suffocating when they lay down, while others were blinded or left with a gaping hole where their nose used to be. It was because of all these wound injuries that facial reconstructive surgery and modern plastic surgery as we know it came to the forefront.
Gun Shot Wounds.
Charles Bell. London: Longman, Hurst, Rees, Orme and Brown, 1814.
Sir Charles Bell, the brilliant early 19th-century Scottish surgeon and anatomist, had already made a name for himself for discovering the difference between motor (moving) nerves and sensory (feeling) nerves in the spinal cord and for describing the paralysis of the face known today as Bell’s palsy. He was also a gifted artist. In this book we have a rare example of both a practicing surgeon and an artist depicting the effects and toll of war on the human body. The paintings are stark and haunting; they serve as a reminder of what these open battles were like and the destruction rendered. Because of such war wounds during and after World War I, modern plastic surgery made many of its greatest advances.
Plaie à la face avec perte de substance [Plague on the face with loss of substance].
Claude Lallemand. Paris: Bechet, Migneret, 1824.
Claude Lallemand was an early 19th-century French surgeon who served in the armies of the Empire. He also trained under the famous French surgeon Guillaume Dupuytren. In this work, Lallemand describes in great detail a facial reconstruction of a young female, who had lost part of her cheek and lower lip from a spreading, malignant pustule.
Clinique chirurgicale [Surgical clinic].
Dominique Larrey. Vol. 2. Paris: Chez Gabon, 1830.
Baron Dominique Jean Larrey was a 19th-century French military surgeon. He served in Napoleon’s Grande Armée and was an important innovator in battlefield medicine and triage. He has often been considered the first modern military surgeon. Larrey initiated modern methods of army surgery, field hospitals, and army ambulance corps. He formulated the rules for triage of war casualties, treating the wounded according to the immediate urgency of need for medical care regardless of rank or nationality. This method of triage is still in use today. Larrey’s writings are still regarded as valuable sources of surgical and medical knowledge and have been translated into many modern languages. Between 1800 and 1840, he published at least twenty-eight books or articles. His son Hippolyte was surgeon-in-ordinary to the emperor Napoleon III. In this volume Larrey discusses his manner of performing a nasal reconstruction. Instrumentation used for the surgery is also discussed.
Perte du nez et des yeux [Loss of nose and eyes]; Prothese de la bouche et de la face [Prosthesis of the mouth and face].
Charles Delalain. Paris: Philipona, 1882.
Charles Delalain was a French surgeon-dentist in the late 19th century. This work, extracted from the review in L’odontologie, is extremely rare. The mask was made in silver and the eyes made of glass. The denture for the teeth was made of vulcanite. The mask sought to replace the areas of the face that were lost or injured from accidents of war. This book also details the description of how to apply the mask.
Der Process der Wundheilung [The process of wound healing].
Felix Marchand. Stuttgart: Verlag von Ferdinand Enke, 1901.
Felix Marchand was a German pathologist of the late 19th and early 20th centuries. He rose to prominence at the pathological institutes in both Halle and Leipzig. He is best known for coining the term atherosclerosis—from the Greek athero (meaning gruel) and sclerosis (meaning hardening)—to describe the fatty substance leading to hardening and narrowing of the arteries. In this pathologic textbook, Marchand describes wound healing from the vantage point of a pathologist. He discusses the origin and progression of wound healing from what was known at that time. Surgeons and doctors for years had been discussing wound healing, and it continues to play a significant role in the practice of every plastic surgeon today.
Chirurgie d’urgence des blessures de la face et du cou [Emergency surgery for face and neck injuries].
Léon Dufourmentel. Paris: A. Maloine et fils, 1918.
Léon Dufourmentel was a 20th-century French surgeon who specialized in maxillofacial surgery and reconstructive surgery. He trained at the hospitals of Paris and then led the clinical faculty of medicine in Paris. During World War I, he was responsible for caring for the gueules cassées (broken faces), which led to the creation of units of maxillofacial surgery. He is also responsible for utilizing a method for the repair of facial wounds. In this method, he described a pedicled vascularized flap from the temporal scalp (popularly called a Dufourmentel flap) and transferred the tissue to the chin area. This tissue transfer was more reliable than a free skin graft. It was his idea to first use prosthetic devices where reconstructions with autogenous tissue failed. The implants used were mostly made of ivory and rubber. In this book, Dufourmentel shares the care and reconstructions performed on those injured.
Plastic Surgery of the Face.
Harold Gillies. London: Frowde, Hodder and Stoughton, 1920.
Considered by many to be the father of modern plastic surgery, Sir Harold Gillies wrote this epic book for surgeons wishing to specialize in plastic surgery. In the early 20th century, plastic surgery was in its infancy and practiced by general surgeons. The advent of World War I brought with it more facial and head injuries than previously because soldiers were in trenches with their heads exposed to new and more powerful weapons. In 1916, Britain officially recognized plastic surgery as a specialty with the founding of the military hospital in Aldershot. Gillies was an ear, nose, and throat specialist from New Zealand who was at the forefront of this newfound specialty. Gillies treated thousands of patients during his time at Aldershot. In this book, he records those experiences, his goal being to share the skills and techniques learned and mastered there. Each anatomic area of the face is depicted with case studies and photographs. Gillies employed skin grafts, flap transfers, tubed surgeries, and even facial prostheses. The advent of antisepsis and anesthesia made these surgeries possible.
Henry Pickerall. New York: William Wood and Co., 1924.
Henry Pickerall was a 20th-century plastic surgeon also from New Zealand. Although not as well known as the other “fathers” of plastic surgery, such as Gillies, McIndoe and Kilner, Pickerall did advance the specialty of facial reconstructive surgery. He was, in fact, the first maxillofacial surgeon in New Zealand. Like Gillies’s, this book was meant to discuss and detail the diagnosis, care, and surgical management of the face. He drew upon his vast experience treating those injured during the war.
“Use and Uses of Large Split-skin Grafts of Intermediate Thickness.”
Vilray Blair. Surgery, Gynecology & Obstetrics 49 (1929).
Vilray Blair was a 20th-century American plastic surgeon specializing in head, face, and oral reconstruction. He was one of the pioneers of modern plastic surgery; his training was occurring during the time of rapid advancements in the specialty. He is credited with many oral and maxillofacial procedures, but in this publication Blair specifically advances the technique of skin grafting. It had been over eighty years since Reverdin used his “pinch grafts,” and since then the techniques had advanced. Blair now advocates thicker split thickness skin grafts. Because of this increased thickness, the applicability of the graft increased. General surgeons were using grafts as well, and the invention of the dermatome helped to create an even thickness of skin that measured approximately fifteen-thousandths of an inch. Burn surgery and rehabilitation was greatly facilitated with the use of skin grafts.
Biologic or Artery Flaps of the Face.
Johannes Esser. Monaco: Institut Esser de chirurgie structive, 1935.
Johannes “Jan” Esser was a 20th-century Dutch plastic surgeon who was credited with many innovative methods of reconstructive surgery on soldiers wounded in World War I. He was a true Renaissance man by being not only a skilled plastic surgeon but also a chess champion and art dealer. He practiced all over the world before settling in Germany. His reconstructive surgical techniques are still employed today, especially with the use of the flap, which is a piece of tissue still attached to its blood supply and transferred to another area of the body in need of that tissue. In this beautifully illustrated and bound book and atlas, Esser describes scores of cases using these flaps for their reconstruction. This book was intended for the new practitioners to reconstructive facial plastic surgery.
“Skin Grafting, a New Method Based on the Principles of Tissue Culture.”
Machtelf Sano. American Journal of Surgery 61 (1943).
Machteld Sano was a 20th-century Belgian physician who sought to advance the principles of skin grafting with the introduction of a fibrin glue that would remove the previous requirement of sutures and pressure dressing for the success of skin grafts. Prior to this, skin grafting was technically very challenging. Here we have the improvement of a surgical technique by use of a biologic substance rather than surgical advancement.