Millard and Gillies’ 5th Commandment of Plastic Surgery: “Thou Shalt Not Bear False Witness Against Thy Defect”

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, codifying a set of principles encompassing practical, technical, and ethical axioms to guide the reconstructive efforts of plastic surgeons [1] (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.

“Of all the liars in the world, sometimes the worst are our own fears.” -Rudyard Kipling

5. Thou shalt not bear false witness against thy defect-

Remember the first time assisting in a contracted scar release? Late lumpectomy defect reconstruction? 

The sense of surprise at how big the actual defect really is, and the huge donor site actually needed? 

Now fast forward to the first time you had pith in a multidisciplinary meeting and ferociously defend your potential donor sites from your colleagues carefree dissection/pins/peripheral lines/turniquets/iliostomy opening. The ability to assess and plan for the actual defect is key in our reconstructive and aesthetic work. 

Application of Kuhnt–Szymanowski Procedure to Lower Eyelid Margin Defect after Tumor Resection” by Dr. Ayato Hayashi et al. nicely demonstrates a structured approach to large defect lower eyelid reconstruction [3]. A challenging aspect of lower eyelid reconstruction is that candidates often have lax skin that seems sufficient for primary closure, up until the true defect is created.

From “Application of Kuhnt–Szymanowski Procedure to Lower Eyelid Margin Defect after Tumor Resection.” Originally published in PRS Global Open.

The authors opted for an inferiorly based Kuhnt–Szymanowski type flap, as opposed to the lateral Millard type flaps. This is an interesting approach to the problem that may prove advantageous in select patients, and could be a valuable addition to the lower lid reconstruction “toolbox.”

It is interesting to note how the authors respected the anatomy and basic surgical approach to lower eyelid defects while emphasizing the added value of their proposed donor site. 

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. Hayashi A, Mochizuki M, Kamimori T, el al., Application of Kuhnt–Szymanowski Procedure to Lower Eyelid Margin Defect after Tumor Resection. Plast Reconstr Surg Glob Open. 2017 February;5(2):e1230.

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