Rebuilding faces
The need to repair the grievous facial wounds of soldiers in World War I led New Zealander Sir Harold Gillies to pioneer plastic-surgery techniques that are still in use today.
The need to repair the grievous facial wounds of soldiers in World War I led New Zealander Sir Harold Gillies to pioneer plastic-surgery techniques that are still in use today.
Soldiers who returned broken and disfigured from two world wars found salvation through the combination of the careful hands and brilliant mind of Sir Harold Gillies. The New Zealander known as the father of plastic surgery developed frontiers as he discovered them, imparting his knowledge so thoroughly that, even today, war surgeons are using the techniques he pioneered.
As deft as he was at healing broken bodies, Gillies also turned his skill to those broken in spirit. He outraged 1920s Britain with breast reduction surgery and later attracted both anger and awe after performing the world’s first sex-change operations. It mattered little to Gillies that such surgery upset the masses or establishment. What mattered was his ability to ease the heartache wrought through nature’s perceived mistakes.
One of his students, fellow plastic surgeon Sir Archibald McIndoe, is generally more widely known. Yet without Gillies, he would never have achieved greatness. And without Gillies, many thousands of lives would have been much worse.
Gillies was 32 when World War I broke out. Anticipating the draft, he joined the Red Cross. In 1915, he was posted to France to work as a general surgeon with a Belgian ambulance unit.
A new level of violence marked warfare in the years 1914-18. Weaponry had become more sophisticated – artillery and machine guns became commonplace and trench warfare developed to meet the new threats. As trenches dominated, so did wounds to the first parts of the body to go “over the top”. But, as Gillies later wrote, the high incidence of “vicious face destruction” was not matched by the death rate. The walking wounded carried horrific scars. There was no established method of caring for those with facial injuries; no British surgeons specialised in plastic surgery.
The impetus to devise and organise the British hospitals that later dealt specifically with facial wounds stemmed from impressions Gillies gained in France, where the surgeons he observed rebuilding faces would provide the inspiration for his life’s work. He returned from France impassioned, and lobbied British army medical authorities for approval to open a specialised unit to deal with facial wounds.
The 200-bed unit, which opened at Aldershot’s Cambridge Military Hospital in January 1916, was too small for the work the war created. Before the 1916 Somme offensive, Gillies was warned to expect a surge of wounded: he prepared for 200, yet 2000 patients were delivered from the first 10 days of fighting. A larger hospital, built to Gillies’ design, opened in August 1917 at Sidcup, Kent, with space for 320 beds, later growing to 600. The expansion brought surgeons from Australia, Canada and New Zealand, with the New Zealanders led by Henry Pickerill, a dental surgeon at the leading edge of developing bone-grafting techniques. Gillies and the Sidcup surgeons performed more than 11,000 operations on 8000 sailors, airmen and soldiers wounded in World War I.
The planning involved in reconstructing faces drew heavily on Gillies’ artistic skills. Before each operation, he would sketch,
mould and even cast a plan of attack and the expected results. For the first time, injuries were painstakingly captured in pastel, then watercolour, and finally photographs to monitor progress and plan procedures.
Gillies pioneered many principles that still form the basic philosophy for reconstructive surgery, if not all surgery. He laid out the principles of reconstruction, bone and cartilage grafting, tissue transfer and burns management.
He began to understand the link between surgical success and the subsequent mental state of the patients.
A NEW BRANCH OF MEDICINE
In 1920, Gillies assured his place in medical history, and silenced many naysayers, with the publication of his textbook Plastic Surgery of the Face. It summarised the discoveries during the war, then gave detailed instruction on the lessons learnt. It established Gillies as the leader in the field and helped emphasise the value of the emerging speciality.
He set up practice with Thomas Kilner, specialising in plastic surgery, and deter- mined to make their new branch of medicine work. As well as having a private practice, Gillies became chief assistant in the ear, nose and throat department at St Bartholomew’s Hospital, London, where he said “plastic surgery became the hospital scrap-basket”. What cases there were, though, “enabled us to inch our way up”. Kilner, likewise, was appointed to London’s St Thomas’ Hospital, where “for the first two years he encountered only stony silence when he entered the doctors’ lounge”, one medical journal author wrote years later.
In Gillies’ favour was the sheer number of wartime patients returning to the community. This ensured the new form of surgery enjoyed a high public profile. However, it also raised concerns through the 1920s and 1930s about the connection between surgery that restored function and that which improved appearance. The term cosmetic surgery “sullied the art of plastic surgery in many eyes”, as one medical writer put it at the time. Gillies carried out breast alteration surgery, for which he was “openly upbraided for daring to alter nature”, his biographer, Reginald Pound, stated.
“Some of the men had had most of their faces blown away; others were left with torn and tortured masks like something out of a horror film.”
For all the controversies the maverick Gillies courted, Kilner was there to act as a balance; the partnership lasted long enough to establish both in the new field beyond the wounded from WWI. Through the 1920s, their work dealt with cleft palates, harelips, riding accidents, industrial accidents and, increasingly, motor accidents.
By 1929, Kilner had tired of being in Gillies’ shadow but his exit set the stage for an extraordinary colonial coup. Gillies and Kilner were at the top of their profession, and by 1939, when war broke out again, they were two of the foremost plastic surgeons known as The Big Four. The other two, who trained and worked under Gillies in the 1930s, were Archibald McIndoe and Rainsford Mowlem. Now three of the world’s four leading plastic surgeons – Gillies, McIndoe, Mowlem – were New Zealanders, just when Gillies’ precious pioneering surgery was gaining some acceptance.
Gillies was the undoubted leader. His fame grew through the decade, starting with his knighthood in 1930, and as plastic surgery secured a footing, he lectured to huge audiences across the world.
McIndoe came by way of the Mayo Clinic in the US, to which he had won a scholarship from New Zealand. The promise of a professorship in London lured him across the Atlantic, where he found no such post existed. He turned to Gillies – the two were cousins once removed – who offered him a post as an assistant. Gillies then got him appointed as assistant plastic surgeon to St Bartholomew’s.
Mowlem arrived in Britain in 1926, as a trained doctor, becoming Gillies’ fourth and most junior partner in 1939.
Gillies, Kilner, McIndoe and Mowlem dominated the field throughout the world: Gillies’ eccentric mastery and Kilner’s balanced methodology would soon be supplemented by McIndoe’s command of public relations during WWII and Mowlem’s careful, clinical experimentation.
With the start of WWII, the Big Four dispersed among the services, but in the realms of plastic surgery legend, it was McIndoe who emerged a giant. Gillies was instrumental in having McIndoe appointed as a Royal Air Force consultant.
Both were strong, forceful characters. This helped Gillies make his way, and name, in WWI. Likewise, McIndoe won concessions and victories for the wounded in his care that would have severely taxed lesser personalities. In doing so, he built on the work of Gillies. But his success was more about moulding the public spirit, rather than reshaping faces, although he was Gillies’ equal, if not better, in the operating room.
In the 1930s, three of the world’s four leading plastic surgeons were New Zealanders, though Gillies was the undoubted leader.
BEYOND THE BATTLEFIELD
WWII began slowly and evolved differently from the first one. The actions of the fighter pilots who fought back wave after wave of bombers captured the public’s hearts and imagination. They returned often with horrific burns. McIndoe faced a similar wave of wounded to that handled by Gillies and the Sidcup team in the first war.
Meanwhile, at Park Prewett Hospital in Basingstoke, Gillies was handling army casualties, who bore similar wounds to those inflicted in WWI, although at a lower rate.
“The injuries with which Gillies had to cope [in WWI], knowing little beyond the historical work on plastic surgery, far exceeded the more spectacular burns of the Second World War,” McIndoe’s biographer,
Hugh McLeave, wrote. “It was human engineering on a large scale, for some of the men had had most of their faces blown away; others were left with torn and tortured masks like something out of a horror film.”
Yet McIndoe’s advocacy for his airmen patients, and his determined public appeals for decency towards the disfigured, meant by the war’s end he was a hero.
Following WWII, Gillies used the skills honed on the wounded for the most controversial procedure he would conduct – the world’s first sex-change operation.
Laura Dillon sought out Gillies after hearing stories of the work done to reconstruct the bodies of soldiers injured in the war. Before the war, Gillies had carried out operations on those with hypospadias, a birth defect that affects the opening of the urethra. He furthered the work rebuilding the genitals of injured soldiers.
Now, though, he was being asked to build a penis from scratch, in defiance of a law that banned “mutilation” of male organs. To get around the law, it appears Gillies carried out the operations in Ireland, where Dillon
was studying at Dublin’s Trinity College medical school, although it’s still something of a mystery. The operations ran from 1946 until 1949, using skin from Dillon’s legs and stomach. In 1951, Gillies carried out the first male-to-female sex change on Roberta Cowell.
Gillies returned to New Zealand only once – in 1955. He was feted on arrival, was given free transport and accommodation and was guest of honour at a special banquet given by Prime Minister Sidney Holland. He returned to England and died in 1960.