Millard and Gillies’ 3rd Commandment of Plastic Surgery: “Honor That Which is Normal and Return It to Normal Position”

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

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).

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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.

“Form follows function—that has been misunderstood. Form and function should be one, joined in a spiritual union.” -Frank Lloyd Wright

3. Honor that which is normal-

Plastic surgery is unique in that the specialty is defined not by the organ or system it treats but the ability mold, shape and replace tissue. Understanding what the normal anatomic is and functional baseline of both donor and recipient sites is the responsibility and privilege of the consulting plastic surgeon.

Microvascular Staged Phalloplasty Preserving Original Glans in a Severe Hypospadias: A Case Report” by Dr. Alessandro Thione et al. demonstrates how previous surgeries have failed to respect the normal position of a 40-year-old males penis leading to progressive physical, psychological and social distress. Breaking down the problem to the anatomic, functional goals and considering the previous reconstructive attempts and their outcome lead the surgeons to a stage microsurgical reconstructive plan.

The surgeons opted for modifications of standard penile reconstruction surgeries. The modification was done honoring the healthy, functional glans and reconstructing the penile shaft using a radial forearm flap and the corpora cavernosa using an osteocutaneus fibular flap.  

 Attempting to reconstruct the “normal” is by no means an easy task. Also, careful consideration of routine surgeries in other specialties, and in our own, may lead to the interesting realization that the “normal” is often sacrificed in the short term for the sake of solving an immediate problem. It might be best to avoid the need for future complex operations by considering the normal structures and their position that may be disrupted by the surgical plan, even if they are not an immediate concern of the surgeon treating the problem at hand.

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.

References:
  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.
  3. Thione A. Cavadas P. Carlos G. Microvascular Staged Phalloplasty Preserving Original Glans in a Severe Hypospadias: A Case Report. Plast Reconstr Surg Glob Open. 2015 December;3(12):e588.
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