Millard and Gillies’ 1st Commandment of Plastic Surgery: “Thou Shalt Make a Plan”

by Or Friedman, MD (@Friedman_MD)
Tel Aviv Medical Center, Israel 
PRS Global Open Resident Ambassador

Millard reported on his mentor Sir Harold Gillies’ “ten commandments of plastic surgery” in 1950,1 codifying a set of principles encompassing practical, technical, and ethical axioms to guide the reconstructive efforts of plastic surgeons (Table 1).

Table 1

Rohrich et al., revisited those commandments and described their practical application during our daily practice.2 We would like to highlight each principle with a resource from PRS Global Open that demonstrates its use.

“Expect the best, plan for the worst and prepare to be surprised” -Denis Waitley

1. Thou shalt make a plan-

Preoperative planning is a fundamental aspect of plastic surgery and an indispensable part of any successful surgical procedure. Benjamin Franklin stated that “By failing to prepare, you are preparing to fail.” Preoperative planning enables the surgeon to anticipate potential complications or difficulties that may arise during surgery while improving communication between operating room personnel. Eventually, this may lead to an increase in the efficiency of use of operating room time and resources with better patient outcomes.

Oliver and Chaiyasate described a challenging case of a late paediatric patient facial reconstruction which demonstrates both long and short term planning which evolved with the progress of the reconstruction (

Initially the problem was defined considering the aesthetic and functional needs of the girl. Then, reconstructive goals were set followed by deciding on the timing of each surgery and considering the donor and recipient sites advantages and weaknesses, making sure to preserve tissue for contingencies and salvage options. It is interesting to note how the authors used almost every “tool in the plastic toolbox” in this series of surgeries and how local and distal flaps as well as simple and complicated techniques were combined to achieve the reconstructive goals.

The benefits of thorough preparation and planning for surgery cannot be overstated.

This is the added value the plastic reconstructive surgery specialty brings to a multidisciplinary consultation. Be it a breast reconstruction case discussing the oncological and reconstructive approach or the 3 AM trauma patient during damage control considering future reconstructive and rehabilitative needs. When a Plastic surgeon is consulted his colleagues expect the best, its up to him to understand and plan for the worst and still be flexible and proficient enough to deal with surprise.

PRS Global Open case reports are a great source for challenging plastic surgery cases and breaking them down to the “ten commandments” may help consolidate our “plastic” approach and reasoning.

  1. Millard DR Jr. Plastic peregrinations. Plast Reconstr Surg (1946) 1950;5:26–53.
  2. Rohrich RJ, Timberlake AT, Afrooz PN. Revisiting the Fundamental Operative Principles of Plastic Surgery. Plast Reconstr Surg. 2017 Dec;140(6):1315-1318.
  3. Oliver LN, Chaiyasate K. Reconstructive Approach to an Acquired Absence of Multiple Facial Components: A Case Report. Plast Reconstr Surg Glob Open. 2016 Oct 28;4(10):e1083.

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