Millard and Gillies’ 9th Commandment of Plastic Surgery: “Thou Shalt Not Have a Routine”

by Lior Har-Shai and Or Friedman, MD
Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical, affiliated with the Sackler Faculty of Medicine
Tel-Aviv University, 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).

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.

“The human spirit lives on creativity and dies in conformity and routine.” -Vilayat Inayat Khan

9. Thou shalt not have a routine.

Surgeons love routines—they keep us safe, confident, and help achieve consistent results. Plastic surgeons, however, practice outside their comfort zone, where no routine exists or it may not be as relevant.

Successful Treatment of Pyoderma Gangrenosum after Augmentation Mastopexy Using Vacuum Therapy by Soncini et al. demonstrates the grave consequences of Post-surgical pyoderma gangrenosum (PSPG) in a 19-year-old woman who underwent aesthetic breast surgery for the correction of breast ptosis and asymmetry.

PSPG is a rare non-infectious cutaneous disease, characterized by a progressive, necrotizing process after skin injury. PSPG is idiopathic and its diagnosis is one of exclusion, requiring a high index of suspicion and a positive response to corticosteroid therapy.

PSPG of the breast is a rare entity. Few cases have been reported following breast reductions and pexies, breast reconstructions, and breast augmentations. 

PG misdiagnosis and its treatment as a severe necrotizing infection can exacerbate the disease and cause devastating aesthetic damage. 

Initially the patient was treated using systemic antibiotics and surgical debridement. Under this treatment, the patient’s condition worsened progressively until the authors re-assessed and started high dose systemic corticosteroids treatment. The patient rapidly improved. The extensive breast ulcers were treated using negative-pressure wound therapy dressings until wounds closure.

This case report may serve as an example of how important it is not to ‘get trapped’ in routine and conventional treatment methods, all the while re-assessing the case and keeping an open mind for less probable diagnosis and their respective treatments.

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. Soncini JA, Salles AG, Neto JA, Gemperli R. Successful treatment of pyoderma gangrenosum after augmentation mastopexy using vacuum therapy. Plastic and Reconstructive Surgery Global Open. 2016 Nov;4(11).

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s