Nineteenth-Century Reemergence

Reconstructive surgery reemerged in the West after the 1794 article on Indian nose reconstruction in The Gentlemen's Magazine . The time had come again for surgeons to explore the possibilities. A British surgeon, Joseph Carpue, successfully reconstructed two noses in 1814 and 1815 using the Indian technique (Patterson 1977, 90–121). Carl Ferdinand von Graefe, a professor of surgery in Berlin , began using the Italian technique in 1816. His first procedure took eleven months to complete. As he gained experience, he gradually developed a German method that combined the first three of Tagliacozzi's six surgical steps to make a nose. Von Graefe's approach to what he called “Rhinoplastik” greatly shortened the time, although the necessity of toughening the skin added to the patient's discomfort. Few other surgeons followed von Graefe's lead. Despite the forehead scar, they found the simpler Indian method more reliable and wanted to spare patients the agony of an arm immobilized over the head for several weeks.

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Although other surgeons did not follow von Graefe's approach to nose reconstruction, he still is considered the founder of modern plastic surgery by most because of the breadth of his reconstructive work ( Rogers 1988). He successfully reconstructed the lower eyelid of a young girl in 1809 by rotating skin from the cheek. He successfully closed a soft cleft palate in 1816, an astonishing feat at the time, and reconstructed a lower eyelid, cheek, and adjacent nasal region using a forehead flap in 1821. He also tried to use detached skin grafts for repairs, but, like other contemporaries who experimented with them, his efforts were not successful. One of von Graefe's contemporaries, Johann Friedrich Dieffenbach, achieved considerable success with the Indian method of nose reconstruction. He improved the procedure in a number of ways, including reducing blood congestion with leeches and reducing the compression of vessels in the pedicle (skin bridge) of the forehead flap by insetting the pedicle, rather than laying it over the intact skin between the eyes (Patterson 1977, 94–99). He simplified von Graefe's technique for closing soft cleft palates and was the first to operate on a hard cleft palate using bone flaps. He also improved techniques to reconstruct the area around the eyes. Dieffenbach published descriptions of his innovations in his highly esteemed book, Die operative Chirurgie (1845). He is most famous, however, for nose reconstruction in severely mutilated faces. When replacement using forehead skin was not feasible, he constructed a complete “nose” on the patient's arm. The process took about six weeks. Then he transferred it to the nose area, immobilizing the patient's arm in a manner similar to the Italian method, but only for about two weeks. Z-plasty emerged in the middle of the nineteenth century and became one of the fundamental plastic techniques in the eye region in the second half of that century ( Rogers 1988). More surgeons began to experiment with flaps for reconstruction. Their efforts were enhanced by the introduction of anesthesia and antiseptic techniques in the latter part of the nineteenth century. The stage was set for successful detached skin grafts.

Jacques Reverdin, a Swiss surgeon working in Paris , usually is credited with the first successful detached skin grafts in 1869, although there are a few earlier reports of successful operations. He, however, attributed the spread of grafting to the earlier work of George Pollock in London (Freshwater 1984).

There is no ambiguity about the subsequent developments; Reverdin's small, pinch-like, free grafts of skin hastened the healing of granulating wounds and led the way to successful larger, thicker, detached skin grafts and split-thickness grafts that contained all of the epidermis but only a thin layer of dermis. By the 1890s most of skin grafting techniques used one hundred years later had been described by nineteenth-century surgical pioneers, although such operations were rare ( Rogers 1988).