Millard and Gillies’ 6th Commandment of Plastic Surgery: “Thou Shalt Treat Thy Primary Defect Before Worrying About the Second One”

by Lior Har-Shai and Or Friedman, MD (@Friedman_MD)
From the Departments of Plastic and Reconstructive Surgery

Rabin Medical Center and Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, 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.

“It’s not denial. I’m just selective about the reality I accept.” -Bill Patterson

6. Thou shalt treat thy primary defect before worrying about the second one.

Donor site morbidity is an inevitable drawback of usingautologous tissue for reconstruction. It can range from scarring to contour and functional deficit. Plastic surgeons are trained to consider the “cost” of reconstruction, and at times it might be tempting to try and mitigate that cost when planning reconstruction. More often than not, compromises done in planning a flap to treat the primary defect may lead to insufficient coverage.  

The Reconstruction of the Donor Site of DP Flap Using Thoracodorsal Artery Perforator Flap by Dr. Masayuki Okochi et al. demonstrates an extreme planning process that enables treatment of both primary and secondary defects. The authors describe the common practice of using a loco-regional Delto-Pectoral flap and the need for skin grafting of the donor site. Alternatively the authors suggest a method of donor site closure using a pedicle TDAP once closure of the primary defect is achieved.

From “The Reconstruction of the Donor Site of DP Flap Using Thoracodorsal Artery Perforator Flap.” Originally published in PRS Global Open.

This work demonstrates creativity with striving for an optimal long term result – in form, function, contour, skin match and avoidance of late skin graft contracture. Every aspect of the surgical plan relays on accomplishing definite closure of the defect at hand before treating the defect caused by the reconstruction, the same goes to treating the complications. These qualities are fundamental for the plastic and reconstructive surgeon. 

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. Okochi M, Okochi H, Sakaba T, Ueda K. The Reconstruction of the Donor Site of DP Flap Using Thoracodorsal Artery Perforator Flap. Plastic and Reconstructive Surgery Global Open. 2017 Oct;5(10).

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