Millard and Gillies’ 4th Commandment of Plastic Surgery: “Thou Shalt Not Throw Away a Living Thing”

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).


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.

“Unless someone like you cares an awful lot nothing is going to get better. It’s not.”
-The Lorax

4. Thou shalt not throw away a living thing-

Aesthetic surgery has historically been advanced thanks to lessons learned from reconstructive surgery. Therefore, the very principles this series attempts to discuss may help guide and form our approach to aesthetic challenges as well.

The Clinical Importance of the Fat Compartments in Midfacial Aging” by Dr. Dinah Wan et al. demonstrates an anatomic evaluation of the face that correlates to aesthetic units. The authors clarify the rationale behind the modern trend in facelifts combining fat grafting as opposed to past techniques in which fat was routinely resected and discarded.


From “The Clinical Importance of the Fat Compartments in Midfacial Aging.” Originally published in PRS Global Open.

Understanding facial proportions and aging is a big part of plastic surgery. A quick look at Dr. Val Lambros’ fantastic project, initially comparing patients’ old and recent photographs and  using the VECTRA 3D system to follow up on patients (and plastic surgeons in ASPS meetings), is enough to convince us that depletion and maldistribution are a significant factor in facial aging.

By finding ways to preserve living tissue, be it fat in the face during a facelift, breast tissue in mastopexy, or oncoplastic surgery, we may not only achieve a more natural aesthetically pleasing result but, more importantly, keep our options open for next interventions. Perhaps these very tissues serve a yet unknown purpose that may reduce complications or help maintain results.

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.
  3. Wan, Dinah MD; Amirlak, Bardia MD; Rohrich, Rod MD; Davis, Kathryn Ph.D. The Clinical Importance of the Fat Compartments in Midfacial Aging. Plastic and Reconstructive Surgery – Global Open: December 2013 – Volume 1 – Issue 9 – p e92.

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