Plastic Surgery Principles – Changes Over The Last 500 Years

Posted January 22, 2017 in Asian Eyelid Lift (Asian Blepharoplasty), Eyelid Lift (Blepharoplasty), Facial Augmentation, Home, Nasal Augmentation, Patient Safety

Dr. Ralph Millard, Jr. (June 4, 1919 – June 19, 2011) as I remember him. He was described as “the most brilliant and creative plastic surgeon alive” at the time.

Dr. Ralph Millard, Jr. (June 4, 1919 – June 19, 2011) as I remember him. He was described as “the most brilliant and creative plastic surgeon alive” at the time.

In the April 2000 issue of Plastic Surgery News, David Ralph Millard, Jr. (June 4, 1919 – June 19, 2011) was described as “the most brilliant and creative plastic surgeon we have alive.” He is perhaps best known for his versatile and widely-used technique for repairing cleft lips, but his contributions to Plastic Surgery, especially reconstructive Facial Plastic Surgery are too many to list. Dr. Millard may also be the person most responsible for the current explosion of K-Pop Plastic Surgery in South Korea, but more on that in the next week.

Dr. D. Ralph Millard

Dr. Millard's portrait from 1937, as it appears on the Asheville Prep School's notable alumni page. He is one of the 10 surgeons nominated “Plastic Surgeons of the Millennium” in 2000 by the American Society of Plastic Surgery.

Dr. Millard’s portrait from 1937, as it appears on the Asheville Prep School’s notable alumni page. He is one of the 10 surgeons nominated “Plastic Surgeons of the Millennium” in 2000 by the American Society of Plastic Surgery.

Though his given name is David Ralph Millard, Jr., Dr. Millard went by his middle name, Ralph. I would only call him Dr. Millard. I read a later edition of his 1957 tome, The Principles and Art of Plastic Surgery Vol I and II, cover to cover, several times during my residency. It remains one of the foundations of modern plastic surgery. Co-authored with another World Famous Plastic Surgeon, Sir Harold Gillies (1882-1960), the first edition originally sold for $35, and is offered today on Amazon for $2500, used.

The Principles and Art of Plastic Surgery

The Principles and Art of Plastic Surgery began in 1564, with famous French barber surgeon Ambroise Paré. Yes, surgeons are descendant from barbers, not physicians, but that’s another story. Ambroise Paré Surgical Principles numbered five:

  1. Take away what is superfluous
  2. Restore to their places things which are displaced
  3. Separate those things which are joined together
  4. Join those which are separated
  5. Supply the defects of the nature

The Ten Commandments of Plastic Surgery

In 1950, Dr. Millard published Sir Harold Gillies’ Principles, also known as the ten commandments of Plastic Surgery:

  1. Thou shalt make a plan
  2. Thou shalt have a style
  3. Thou shalt honor that which is normal and return it to normal position
  4. Thou shalt not throw away a living thing
  5. Thou shalt not bear false witness against thy defect
  6. Thou shalt treat the primary defect before worrying about the secondary one
  7. Thou shalt provide thyself with a lifeboat
  8. Thou shalt not do today what you canst put off until tomorrow
  9. Thou shalt not have a routine
  10. Thou shalt not covet thy neighbor’s plastic unit, handmaidens, forehead flaps, Thiersch graft, ox cartilage nor anything that is thy neighbor’s

These principles can be applied to most of life’s pursuits. Elaboration on how the commandments are applied to skating for example, is available in this publication from the Archives of Plastic Surgery entitled, “Plastic Surgery and Aggressive Skating: Can Business Mix with Pleasure?” The Articles from Archives of Plastic Surgery appears on the National Center for Biotechnology Information website and was collected from PubMed Central (PMC) as part of US National Library of Medicine and the National Institutes of Health. Interestingly, the footnote states, “Articles from Archives of Plastic Surgery are provided here courtesy of Korean Society of Plastic and Reconstructive Surgeons.” However, it is still not time to talk about Korean Plastic Surgery.

But Wait, There’s More

The Principles And Art Of Plastic Surgery -Sir Harold Gillies, CBE, FRCS, and D. Ralph Millard, Jr., MD, Assistant Clinical Professor of Plastic Surgery, University of Miami, Florida. Little, Brown and Company, 34 Beacon Street, Boston, 1957. In Two Volumes, Boxed. 690 pages, 2472 illustrations, 122 in color. Original price $35.00 new. Current Amazon price over $2500 used.

The Principles And Art Of Plastic Surgery -Sir Harold Gillies, CBE, FRCS, and D. Ralph Millard, Jr., MD, Assistant Clinical Professor of Plastic Surgery, University of Miami, Florida. Little, Brown and Company, 34 Beacon Street, Boston, 1957. In Two Volumes, Boxed. 690 pages, 2472 illustrations, 122 in color. Original price $35.00 new. Current Amazon price over $2500 used.

In 1957, six more principles were added in the book mentioned above, The Principles and Art of Plastic Surgery. Through the course of his life, eventually these became Dr. Millard’s 33 Commandments of Plastic Surgery. Most are aligned with the more fundamental and self deprecating KISS principle: Keep It Simple Stupid. The complete list can be found on the Internet Scientific Publication Website.

You Can’t Go Wrong With Good Principles

To me, these simple guiding principles are Dr. Millard’s greatest contribution to Plastic Surgery. Others will argue that one or another of the specific techniques he adapted or improved are more important, but commandments two, nine and ten say to me: Plastic Surgeons should keep evolving and not solely rely on the past or a technique. The commandments are a simple and yet effective framework with which to refine current techniques and to evolve the future of Plastic Surgery.

So What About South Korea?

Two of Dr. Millard’s most famous techniques are the rotation-advancement flap for the correction of the Cleft Lip and Palate Deformities, and the Double Eyelid Surgery or as it is called in the US, Asian Blepharoplasty. Both of these were developed while he was Chief Plastic Surgeon to the U.S. Marine Corps during the Korean War. How this led to the boom in Korean Plastic Surgery 60 years later is the subject our next San Francisco Plastic Surgery Blog post.