Medicine: Flap Happy?

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Many a plastic surgeon thumbing through a handsome, two-volume medical work last week was startled to find, under the unscientific heading, "Oops!", this homely advice: "Once a graft has been cut, it should be folded, wrapped in a damp gauze and put in a safe place until time for its application. Too often in its trip around the theatre it gets thrown in the wastebucket or dropped on the floor. Pick it up. wash it and get on with the job. It happens in the best of clinics!" And, as the kickoff to a chapter entitled "Flap Happy," there are these wry definitions: "A graft is a piece of detached skin which is dead when you put it on and comes to life later. A flap is a partly attached piece of skin which is alive when you put it on and may die later."

Such salty, down-to-earth treatment of an esoteric surgical specialty could have come only from New Zealand-born Sir Harold Delf Gillies, 74, onetime champion golfer, master of the fly rod, amateur painter and undisputed father of modern plastic surgery in Britain. As co-author of The Principles and Art of Plastic Surgery (Little, Brown; $35), he enlisted the University of Miami's David Ralph Millard Jr., 37, a kindred spirit and former pupil. Utterly different from anything else in the field, their work is neither a set text nor a formal reference book, but a remarkable grafting of plastic surgery history and techniques onto a chatty life history of Innovator Gillies (known to colleagues as "Giles"). Its 2,300 illustrations comprise an unprecedented gallery of human faces and limbs deformed from birth, shattered by shot and shell, smashed in accidents, maimed by disease or burned to hideous unrecognizability. Yet his before-and-after sequences end with a happy improvement, and in many cases there is restoration to completely normal appearance.

Breasts, Noses. In special cases, says

"Gillies, the plastic surgeon is well advised to aim short of perfection. "It is important to remember when remaking the nose for a one-eyed lad not to build the bridge so high that he cannot see the motor bus coming from the blind side." This reminds him of the one-eyed Count of Montefeltro (1422-82), who deliberately had part of his nasal bridge removed: "Thus his one good eye peeking through the notch in his nose discouraged friends sitting on his blind side from trying to poison him."

In other matters, Gillies is a perfectionist. He has no use for the cancer surgeon who removes a woman's breast and suggests no replacement. Gillies makes an incision from below the armpit, across the abdomen, around the navel and back again. With the flesh thus released, he constructs a tube pedicle flap,* and as he brings it around to the side of the missing breast, the inside-out navel (concave to convex) takes the place of the nipple. After this surgery, a woman has an abdominal scar but no deformity. In some patients, as a result of an embryonic failure, a breast may be missing, with only a nipple present; in such cases, Surgeon Gillies has built a mound of tissue under and around the nipple. In one case, he notes: "With marriage and pregnancy, the diminutive portion of breast tissue increased greatly and enabled lactation to occur through this new breast."