Some pioneers in plastic surgery of the facial region.

Abstract

Archives of Facial Plastic SurgeryVol. 5, No. 1 Special TopicsFree AccessSome Pioneers in Plastic Surgery of the Facial RegionRoger L. CrumleyRoger L. CrumleyCorresponding author and reprints: Roger L. Crumley, MD, MBA, University of California, Irvine, Medical Center, Department of Otolaryngology–Head and Neck Surgery, 101 The City Dr South, Bldg 25, Room 191, Orange, CA 92868.From the Department of Otolaryngology–Head & Neck Surgery, Division of Facial Plastic Surgery, University of California, Irvine.Search for more papers by this authorPublished Online:1 Jan 2003https://doi.org/10.1001/archfaci.5.1.9AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The history of plastic surgery of the facial region is rich and varied. A wide array of specialties and disciplines have contributed to this history. In some instances an individual practitioner was able to advance his or her specific interest and/or expertise. Others made their contributions by describing what prior surgeons had done and adding their own innovations. Certainly wars contributed substantially to advancement and refinement of the craft, particularly World War I with its trench warfare and manifold maxillofacial injuries.Much of this complex history comes from Europe, with contributions and advances from dentists, otolaryngologists, and general surgeons. Prior to World War I there was no specific plastic surgery specialty. For example, Sir Harold Gillies, an otolaryngologist, learned many dental skills and techniques from Charles Auguste Valadier, a rogue French practitioner of dentistry and maxillofacial surgery. (Valadier is said to have treated most of his patients in an automotive vehicle described as a "traveling dental parlour" around 1900.) Gillies, extraordinarily innovative, technically superb, and politically adept, was called by some the "father of plastic surgery," although such a descriptor probably does not pay proper homage and credit to his many European predecessors. Gillies drew heavily from these surgeons and teachers in Britain and continental Europe, as they themselves had advanced their own training and expertise.Hence it would be unfair and inappropriate to characterize any single individual as the main leader, pioneer, or "father" of plastic surgery. In this brief and partial treatise on the subject, an attempt will be made to memorialize some of the many contributions and contributors to the art, science, and craft of plastic surgery of the face, particularly since 1800. In this article, the excellent work of surgeons from India in reconstructing noses amputated as punishment (usually for adultery) and the "Italian school" of Tagliacozzi et al, will be mentioned here only as a strong prior basis for facial surgical advances of the early 1800s. Joseph Carpue (1764-1846, London) was one of the earliest surgeons interested in nasal and facial surgery. He described restoration of a "lost nose" as early as 1816.1EARLY US AND EUROPEAN SURGEONSClearly one of the earliest and most prominent surgeons known for reconstructive and plastic surgery in the first part of the 19th century was Dieffenbach, who documented many of his experiences in Operative Surgery, published in 1845. In this text he described such techniques as "nasal reduction" (excision of a portion of an abnormally enlarged nasal ala) and a second "reduction" consisting of cruciate excisions of skin and cartilage. Accordingly, reduction rhinoplastic procedures were clearly established prior to 1850.The Italian surgeon Sabattini described cheek and lip switch flaps in 1837. In 1847, Sophus A. V. Stein (Denmark, 1797-1868; Figure 1A) depicted his lip switch flap, using a pedicled flap of upper lip to reconstruct lower lip defects resulting from carcinoma excision.2 Jacob A. Estlander (Finland, 1831-1881; Figure 1B) subsequently described an upper-to-lower switch technique for lower lip defects for carcinoma as well as typhoid gangrene.2Figure 1. A, Sophus A. V. Stein (Denmark, 1797-1868) described upper lip pedicles to lower lip defects. B, Jacob A. Estlander (Finland, 1831-1881) performed lip switch flaps for carcinoma and typhoid gangrene. Reproduced with permission from Stark.2Meanwhile in the United States, one of the earliest facial reconstructive surgeons was Gurdon Buck (1807-1877; Figure 2A). Buck worked at New York Hospital and was particularly active during the US Civil War, during which time he reconstructed the faces of patients with war injuries. One particularly well-illustrated case was that of Private Carleton Burgan, who had lost his nose, cheek, and orbital floor to an overdose of calomel (mercurous chloride) (Figure 2B). Using forehead and facial flaps, Buck successfully reconstructed Burgan's nose and face, with an assist from a "skillful dentist" (Thomas Gunning).2Figure 2. A, Gurdon Buck (New York, 1807-1877) Civil War–era plastic surgeon. B, Buck's multiple facial reconstructive procedures performed on Private Carleton Burgan. Reproduced with permission from Stark.2To summarize the progress during the 19th century then, it is clear that rhinoplasty, otoplasty, and other facial plastic surgical procedures were being performed by a number of surgeons on both sides of the Atlantic. Hippolyte Morestin (1869-1919) was a well-known plastic surgeon in Paris, although he was born and educated in Martinique, where he started his practice. He described serial excision (gradual reduction) among other techniques. In the United States, that technique was subsequently called staged removal by W. E. Sistrunk, gradual partial reduction by J. S. Davis, and multiple excisions by Ferris Smith of Grand Rapids, Mich. (Figure 3).2Figure 3. Four early surgeons used 4 different terms to describe the procedure now known as serial excision: A, Hippolyte Morestin (Martinique and Paris, 1869-1919) called it gradual reduction; B, W. E. Sistrunk (Mayo Clinic), staged removal; C, John Staige Davis (Johns Hopkins), gradual partial reduction; and D, Ferris Smith (Grand Rapids, Mich), multiple excisions. Reproduced with permission from Stark.2There were other surgeons who began to practice cosmetic surgery, but several were considered outside of the mainstream of the new plastic surgery movement. Notably, Charles Conrad Miller published a cosmetic surgery text in 1907 titled Cosmetic Surgery: The Correction of Featural Imperfections.3 Madame Noel similarly published textual material regarding her cosmetic surgery practice in Paris in the early 1900s.4The advanced state of European surgery naturally attracted many American surgeons and other educators to Europe. The effects of this European training combined with the training received in this country was to be felt in US surgical education for at least 150 years. For example, Dr William Welch, after graduating from Yale medical college, traveled to Europe to gather ideas about starting a new medical college in Baltimore, Md. While in Europe, Welch came under the influence of Christian Albert Theodore Billroth, whose education included emphasis on Latin, Greek, history, geography, mathematics, and modern languages. Billroth was extensively trained in Gottingen, Berlin, Vienna, Paris, and Zurich. While working at Berlin's Charité Hospital (established by King Frederick Wilhelm III in 1818), Billroth worked directly under Langenbeck, one of the first successful cleft palate surgeons in Europe.US-EUROPEAN INTERACTIONThis rich environment of European academic medicine, exemplified by Billroth and Langenbeck, was intriguing and attractive to Welch. He decided to emulate it in Baltimore with an endowment given by a man named Johns Hopkins.5 Welch became the first dean of the College of Medicine at Johns Hopkins. He recruited William Stewart Halsted to become the first chairman of surgery. Like Welch, Halsted was a Yale graduate who spent several years (1878-1880) in Europe, studying surgery under Chiari, Fuchs, Zuckerkandl, and Billroth.6 At Hopkins, Halsted was a contemporary of Sir William Osler (Hopkins' chairman of medicine). The 2 of them wrote guidelines for residency training and insisted that the Hopkins faculty adhere to them. These guidelines included the treatment of lower-income patients as a means to enhance resident surgical experiences and use of the so-called Socratic method of quizzing house staff and expecting answers.The Hopkins connection became even more interesting for plastic and facial plastic surgeons. Halsted performed a variety of pedicle flaps, grafts, and even some pioneering work with hindlimb transplants when he dissected the entire hindlimb except for leaving the main artery intact (beginnings of free-flap thinking).6 Jerome Pierce Webster spent 1 year in Halsted's program and subsequently asked Halsted to find him placement in the World War I Medical Corps. Halsted wrote to J. Eastman Sheehan in New York regarding one of Gillies' cases. One of Halsted's most important moves for early plastic surgeons was his recruitment of John Staige Davis, who wrote the first comprehensive text of plastic surgery in the United States in 1919.7Davis was trained in general surgery but preferred reconstructive and plastic procedures and problems. He and Halsted were the 2 most influential surgeons on the Hopkins faculty in the early 20th century who advanced the status of plastic surgery. The influence of Davis is poignantly described by an elderly plastic surgeon who elaborated how he, as a 5-year-old boy hospitalized at Hopkins for severe bronchial asthma, had the occasion to watch Davis on the wards at Hopkins, observing his "kind and gentle nature"8 as he changed dressings in the evenings. He was particularly impressed when Dr Davis let him assist with the dressing cart. The boy became so enamored of Davis, his soft and gentle persona, and his practice, that he decided at that early juncture that he must become a plastic surgeon. The young boy was none other than Richard Webster, one of the most prolific surgeons and teachers of rhinoplasty, otoplasty, and other facial plastic surgery in the latter half of the 20th century. Webster subsequently became President of the American Academy of Facial Plastic and Reconstructive Surgery. Two of his many superb articles chronicle in mesmerizing detail the early dynamics of plastic, facial plastic, and cosmetic surgery in the era when cosmetic surgery was struggling for acceptance among the wider surgical community.8,9JACQUES JOSEPHWith respect to nasal plastic surgery, one European surgeon stood out as particularly noteworthy, the legendary Jacques Joseph (Berlin, 1865-1934) (Figure 4).10 Although American John Orlando Roe (Rochester, NY, 1849-1915) actually described endonasal rhinoplasty first ("pug nose" operation, 1887),11 Joseph eloquently described rhinoplasty in his book(s) and writings. These 2 surgeons, along with Robert F. Weir of New York,12 should be credited with moving rhinoplasty to the forefront of modern plastic surgery. Blair Rogers13 details how Roe performed many endonasal procedures prior to Joseph's first external procedure, which largely used techniques described by Dieffenbach 50 years previously. However, Joseph may well deserve the designation "father of rhinoplasty." His meticulous photography, reduction rhinoplasty results, and persistence in designing new instruments were responsible for the training of nasal surgeons worldwide. Many if not most early rhinoplasty surgeons in the United States spent time in Joseph's operating theater, and in fact many of them paid dearly for the right to do so. The rhinoplasty surgical armamentarium today includes many instruments originally designed by Joseph, even if refined or modified by others (Joseph knife, Joseph saw, Aufricht retractor, Fomon rasp, and others).Figure 4. Jacques Joseph (Berlin, 1865-1934). Reproduced with permission from Joseph.10Joseph's interest in plastic surgery initially got him into trouble: he was terminated from an orthopedic training program because he had performed an otoplasty (apparently after reading Ely's original article14 on otoplasty). He went on to focus on plastic surgery, particularly nasal and facial, introducing a wide variety of innovations in surgery.15 It was he who established a facial plastic surgery clinic at Humboldt University in Berlin. There he developed first his external rhinoplasty (using dorsal incisions for hump reduction), which evolved into his closed endonasal technique subsequently described in 1898. Because there were as yet no antibiotics, he was particularly interested in aseptic technique. This interest led him to develop a no-touch instrument suture technique, the "apodactylic" suture for "especially strict asepsis." It is fortunate that those of us performing surgery today do not have to tie sutures this way, as it required 2 forceps for the surgeon and 2 additional forceps for the nurse to complete the knot tying (Figure 5).10Figure 5. Joseph's no-touch suture technique ("apodactylic suture"). Reproduced with permission from Joseph.10Keeping surgery orderly, Joseph used what he called a "silent assistant," which consisted of a sponge tray, instruments, and a T-bar device located over the patient's head (Figure 6). Yet another innovation in his operating room was the "osteoplastic workplace," where he used a variety of sterile hardware, files, and rasps to sculpt tibial and iliac bone grafts for rhinoplastic insertion (Figure 7). It appears that he most probably harvested these grafts without general anesthesia, describing a "moderate bromide dose" administered 2 hours prior to surgery for sedation. Joseph's reputation flourished, particularly after an open-air (convertible) Berlin taxi driver, known for a particularly large and disfiguring nasal hump, suddenly appeared driving about the city with a straight and artistic nasal dorsum. Joseph considered aesthetic analysis a critical component of achieving excellent results and developed an "apparatus for direct determination of the aesthetic profile angle,"10 which he called the profile angle meter (Figure 8).Figure 6. The sponge tray and instruments, as well as a T-bar device (not pictured) located over the patient's head, comprise Joseph's "silent assistant," a substantial aid to the surgeon during rhinoplasty. Reproduced with permission from Joseph.10Figure 7. Joseph's "osteoplastic workplace" for sculpting tibial and iliac bone grafts. Reproduced with permission from Joseph.10Figure 8. Joseph's "apparatus for direct determination of the aesthetic profile angle," or profile angle meter. Reproduced with permission from Joseph.10Among the many surgeons who traveled to Berlin to observe Joseph was Sam Fomon of New York. Fomon had little surgical training, but he was particularly bright, eager to learn, and had interest in and knowledge of anatomy. Fomon was particularly interested in Joseph's instruments, which the German was not willing to openly demonstrate or illustrate. Rather, he hid them under a towel during surgical procedures when there were observers present. Fomon was aware of this and is said to have paid a nurse for access to the operating room late one night, at which time he photographed the entire set of instruments. Hence many of Joseph's instruments and techniques eventually found their way to the United States, and nasal surgeons on this side of the Atlantic were quick to embrace the newer techniques and instruments in the operating room (eg, the "Fomon" rasp).Not all rhinoplastic contributors can be mentioned here, but another New York nasal surgeon, Robert Weir12 (1838-1927), described crescentic excisions of the nasal alae in 1892. Such procedures are still known as "Weir excisions." Shortly after Weir's article was published, George H. Monks16 (Boston, Mass, 1853-1933) described a temporal island flap technique for eyelid reconstruction, and sometime later he used the island technique for reconstruction of the eyebrow.A New York otolaryngologist named Edward Ely first described the correction of protruding ears with an operation destined to become known as otoplasty.14,17 Ely, son of a Rochester, NY, physician, saw the necessity of excising conchal cartilage in addition to skin. He was subsequently given credit for being the first to describe otoplasty by none other than Jacques Joseph10 in his classic plastic surgery text. This classic first article on protruding ear correction was written by Ely at age 31, and his life was ended tragically early at age 35 by pulmonary tuberculosis. Rogers noted Ely's pioneering contribution by noting, "Like many otolaryngologists, he seemed to be utilizing, more and more, the techniques in the then slowly developing field of plastic and reconstructive surgery."17In the earliest part of the 20th century, one of the most prominent plastic surgeons in the United States was John Staige Davis at Johns Hopkins (Figure 3C). His text Plastic Surgery: Its Principles and Practice7 enunciated his predilection and passion for plastic surgery rather than general surgery. Davis cited Halsted's contributions to "waltzing flaps" in his book. Indeed, Halsted (who wrote several articles regarding tissue transfer and other reconstructive techniques) appears to have delegated much of the early Hopkins "plastic work" to Davis.6Meanwhile, in Europe, plastic surgery continued to develop in Vienna, Paris, and Berlin. In this setting, a young London otolaryngologist named Sir Harold Delf Gillies (1882-1960) traveled frequently to Paris to learn the newer plastic techniques. Gillies was born in New Zealand on June 17, 1882. His father had been born in Glasgow, Scotland, and raised in that area, but after moving to New Zealand he was elected to the parliament there.18 His mother was of Danish descent. Little Harold demonstrated musical and athletic talent in grade school and subsequently attended Cambridge, where he joined the rowing team and excelled at golf. In fact, he won the British amateur championship several times. He finished his otolaryngologic training at St Bartholomew's in London, and when World War I broke out he was 32 years old. The Red Cross sent him to France, where he worked first with a Belgian ambulance unit. This is how he met Charles Auguste Valadier (1873-1931).Valadier was a colorful historical character. Since he had a major influence on Gillies, comment on his life is worth a brief digression. He was born in France, but his father moved to the United States 3 years thereafter.19 Accordingly, Valadier become an American citizen. He attended the College of Physicians and Surgeons at Columbia, and claimed to have a medical degree from that institution. Subsequently, he was said to have obtained a dental degree from the Philadelphia Dental College. He also had very little or no postdegree dental training. It has been speculated that he conducted an "advertising" dental practice subsequently in New York City, hence barring himself from membership in any of the traditional dental societies.20 Responsive to his widowed mother's urgings, he moved to Paris. He apparently obtained some additional French dental education, but he did not graduate, nor did he achieve full French certification in dentistry.Despite these limitations, Valadier developed in Paris a robust practice, using dental, surgical, and prosthetic techniques largely performed in a Rolls Royce motor car he called a "traveling dental parlour." He was also known to be experimenting with bone-grafting techniques. Gillies studied Valadier's techniques and learned much that he subsequently used in treating facial war wounds. After Gillies became established, he rarely acknowledged Valadier for this training, probably because of Valadier's lack of formal medical or dental background.19While in Paris, Gillies also came under the influence of Hippolyte Morestin, the most prominent surgeon in France, and indeed in Western Europe (Figure 3A).18 Morestin, who was described as "an unpredictable Creole from Martinque," let Gillies watch an operation for cancer of the face. Observing Morestin and Valadier created in Gillies a burning dedication to plastic surgery, particularly of the face. Meanwhile, the British Red Cross began setting up a small London hospital for facial wounds and asked Gillies to oversee it. He became interested in cartilage grafts and called on Morestin to visit and observe. This time, Morestin refused him entry to his operating room.Undeterred, Gillies set up a hospital (Aldershot) in London to treat World War I facial wound patients. He carefully studied the advances of Jacques Reverdin (1869) who first popularized skin grafting, as well as Thiersch and French skin grafting pioneer Lewis Ollier.18 Sir Harold's hospital subsequently moved to a larger site (Queen's Hospital, Sidcup, Kent), where he treated most of his World War I patients. Many dental, otolaryngologic, general, and plastic surgeons visited and trained, learned, and developed at Sidcup. Gillies worked feverishly during the war, but even then, as later in his life, he somehow found time for his beloved hobbies of painting, golf, and trout fishing.Of the many innovations for which Gillies became known, the "tubed pedicle flap" is probably the most well known. Medical historians, however, have elucidated that the Russian Vladimir Filatov (1916) first described the tubing of a pedicled flap. Sir Harold was unaware of this development, however, and thought that the tubed pedicles performed in his unit at Sidcup were the world's first. It was not until a trip to the United States that he learned (from Ferris Smith in Grand Rapids, November 1919) of Filatov's case and report preceding his. This was said to have caused him great concern and anxiety, although he subsequently confirmed Filatov's report and dates.18THE FLAP OF (OR OVER) CAPTAIN J. L. AYMARDEven at Sidcup, there was controversy regarding who performed the first tubed pedicle flap procedure (1917). Gillies was the head surgeon and leader of the surgical service at the hospital and claimed credit. One of his recruits, however, was a South African otolaryngologist named G. L. Aymard. There are several accounts of which of these 2 surgeons (Gillies or Aymard) performed the now-famous tubed pedicle procedure first at Sidcup. According to Gillies, he (Gillies) reconstructed an orbit with a tubed pedicle flap on October 18, 1917, and Aymard heard about the case and performed a second one, trying to take credit. Aymard's version is that his (Aymard's) case was first, and that Sir Harold learned of his technique through the other surgeons at the hospital and subsequently performed his case. Whoever was first, the debate created considerable acrimony, which resulted in Gillies sending Aymard home to South Africa, where he continued to claim he originated the technique. Aymard made several other contributions and was in fact cited subsequently in the pioneering plastic surgery text of John Staige Davis.7There are several biographies and other texts covering the life of Gillies. One of the best is Gillies: Surgeon Extraordinary, by Reginald Pound, published in 1964.18 This book leaves its readers with a clear understanding of the depth of Gillies' ingenuity and creativity for facial reconstruction and surgery in general. He frequently "pushed the envelope," and had surgical disasters, flap losses, and other setbacks that left his many admirers and trainees raising their eyebrows. However, his successes were truly spectacular, and his photography enabled him to publicize these successes in Europe and the United States.Far more than just an innovative surgeon, Gillies ("Giles" to his friends and associates) was also known for his total disregard for punctuality, sometimes reckless driving, legendary golf accomplishments, and long hours on the trout stream. Furthermore, he demonstrated such disregard for rules, formality, and even social taste (on some occasions) that it is indeed remarkable that he was eventually knighted. He was a consummate practical joker, sometimes disguising himself at prestigious social gatherings, and terrorizing his golfing mates by substituting exploding golf balls and other bizarre versions of golf balls when their backs were turned.Unfortunately, Gillies paid little attention to money, and in his later years he frequently declined speaking tours to continental Europe, the United States, and other countries, saying he could not afford to go. However, he is said to have made students and visiting surgeons a top priority and continued teaching his craft until the time of his death in 1960.Perhaps Gillies' greatest contribution to medicine and to the development of plastic surgery and facial plastic surgery was the long list of illustrious plastic, dental, and otolaryngologic surgeons he trained in maxillofacial surgery (mostly at Sidcup). Of this group, 2 prominent British surgeons, Kilner and McIndoe, spent time learning from the master and later became partners in a London practice after the war. Others included Robert Ivy, Ferris Smith (Grand Rapids), J. Eastman Sheehan (New York), John Staige Davis (Johns Hopkins), Vilray Blair (Washington University, St Louis), Sterling Bunnell (San Francisco), D. Ralph Millard (Miami), Hugo Obwegeser, Gustave Aufricht (New York), Sir Ivan Magill, Neal Owens (New Orleans), and many others.As an otolaryngologically trained facial plastic surgeon, I became particularly interested in how one otolaryngologist and Gillies trainee in particular, Ferris Smith (1884-1946), used his Sidcup training on returning to the United States after World War I. Smith finished an otolaryngology residency at the University of Michigan in approximately 1914 and remained on the faculty in Ann Arbor for 2 or 3 years. When World War I broke out, his father, a Michigan legislator, arranged for his son Ferris to spend his military time with Gillies in England. On his return, Smith embarked on a busy private practice of otolaryngology and facial plastic surgery in Grand Rapids, Mich. Gillies and many other US plastic surgeons visited Smith there (J. D. Miller, MD, Grand Rapids, Mich; personal communication, May 1987).Since considerable rancor subsequently developed between the 2 specialties (otolaryngology–head and neck surgery and plastic surgery), it is interesting that Ferris Smith practiced both specialties most of his career. He tried to convince the otolaryngology community about the important and evolving role of plastic surgical techniques for otolaryngologists at otolaryngology and American Medical Association meetings. His message was perhaps most clearly delivered in an article titled "Plastic Surgery: Its Interest to the Otolaryngologist," published in 1920.21 With regard to otolaryngologists and plastic surgery, Smith notes (in reference to his time at Sidcup), Brilliant among these contributors were the otolaryngologists and oral surgeons. It may be fitting in this connection to note that the entire British and Canadian operating staff of the Queen's Hospital at Sidcup during my duty there were surgeons representing these specialties.21In this article, Smith reviews many cases of facial and nasal reconstruction that used grafts and flaps. He describes defect closures by the French technique (advancement flaps), interpolation flaps such as the Indian forehead flap, the tubed pedicle of Gillies/Aymard/Filatov, and the "Italian method of transfer by attachment to a wrist carrier."21 His other articles reflect his interest in the newly evolving specialty of plastic surgery with verbiage such as "plastic vocal cord," "planning the reconstruction," "multiple excision and Z plastics in surface reconstruction," and many others describing plastic surgical and more classic or core otorhinolaryngologic disorders and techniques, exemplifying his plastic training and influence (Figure 9).Figure 9. Ferris Smith, sometime around 1920, inserting a graft during a nasal reconstructive procedure.None of what Smith wrote reflected what Gillies told or taught him regarding the latter's opinions of otolaryngologists or plastic surgeons. However, it seems apparent from other sources that Gillies forsook his original specialty of otolaryngology and espoused the newer specialty of plastic surgery. In this regard one has only to read the vitally germane papers of Richard Webster8,9 to understand the mentality of American surgeons (plastic, otolaryngologic, and general) in the first 70 years of the 20th century to understand how most surgeons even remotely connected to plastic surgery attempted to distance themselves from cosmetic surgery, and how this affected development of the new specialty of plastic surgery. If one has any interest whatsoever in the history of plastic surgery and of facial plastic surgery, these 2 articles are absolutely essential.8,9With regard to Ferris Smith, he clearly belonged to the leadership of the emerging specialty of plastic surgery. He fraternized and reciprocated visits with John Staige Davis, J. Eastman Sheehan, Neal Owens, and Vilray Blair. He trained some of the leaders of the next generation of plastic surgeons such as Clarence Straatsma, Reed Dingman, Wallace Stephenson, and Mark Gorney. He was a founding member of the American Board of Plastic Surgery. Indeed he felt compelled to write an article in Plastic and Reconstructive Surgery amending or correcting some of Ivy's previous comments on that board's original organization.22,23 In this regard, it appears that Ferris Smith thought that the new plastic surgery board should be balanced geographically and that older surgeons who did not have formal training needed to be phased out. Apparently, several others differed with him on this issue.In any event, Smith (and most of his US contemporaries in plastic surgery) was trained by Gillies, who in turn had been motivated and trained by his European predecessors. This is but one more unmistakable example that plastic surgeons and facial plastic surgeons share a colorful and historic legacy, with roots in oral surgery, dentistry, otolaryngology, and general surgery.