Renaissance

A fourteenth-century Flemish surgeon, Jehan Yperman, described how to repair harelips, as did sixteenth-century French Huguenot Ambroise Paré, widely regarded as the most skilled surgeon of the Renaissance (Rogers 1988). Paré also described many eyelid repairs, but he apparently did not appreciate the reconstructive surgical techniques used in the south of Italy , techniques that laid the cornerstone of plastic surgery in the Western world.

Branca, a fifteenth-century barber-surgeon from Catania in Sicily , reconstructed noses using cheek flaps (Patterson 1977, 3–14). His son Antonio substituted a partially severed upper arm skin flap for a forehead flap to avoid additional scarring on the face. He also used upper arm flaps to reconstruct lips and ears. How many others, if any, engaged in reconstructive surgery in fifteenth-century Europe are unknown; secrecy surrounded such operations. The Vianeo family (also know as Vianeus and Bojanis) reconstructed facial features from the early to mid-sixteenth century in nearby Calabria . They, too, left no personal records, although Leonardo Fioravanti, a trained surgeon from Bologna , published a description of their procedure in 1570 (Santoni-Rugiu and Mazzola 1997).

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The “Italian method” was grueling. Patients had to endure numerous operative procedures without anesthesia. They also suffered the pain of having their arms immobilized over their heads for several weeks to allow the flap of skin cut from the upper arms to remain attached to the arm's blood supply while the edges of the flap, sutured over the nasal area, had time to adhere. Afterwards the arm connection was severed and the flap was sewn above the lip. The new nose was shaped with nostril openings. Although there is no evidence that Fioravanti attempted a nose reconstruction, his account provided the information necessary for others who were willing to try such a complicated, lengthy, and painful procedure.

The challenge was taken up by Gaspare Tagliacozzi (also known as Taliacotius, Taliacott, Tagliacozza, and Tag). He was a medical student at the University of Bologna when Fioravanti was accepted into the famous Collegio de' Dottori of Bologna. Tagliacozzi did lip and ear reconstructions, as well as noses, using arm skin flaps. Two years before his death in 1599 and after more than a decade of reconstructions with attached flaps, he published the first book devoted to plastic surgery, De Curtorum Chirurgia per Insitionem . In it he clarified his purpose: “We bring back, refashion and restore to wholeness the features which nature gave but chance destroyed, not that they may charm the eye but that they may be an advantage to the living soul … the end for which the physician is working is that the features should fulfill their offices according to nature's decree” (qtd. in Brown 1986).

Tagliacozzi's forthright acknowledgment of his work made him both famous and infamous. On the one hand, he was memorialized by colleagues and students in statues erected at the University of Bologna and the University of Padua after he died. On the other hand, his remains were rumored to have been exhumed from a church cemetery and reburied in unconsecrated ground after reports that a disembodied voice cried out at night, “Taliacotius is damned” (Updegraff 1938). All copies of his book were ordered destroyed when the church tried to halt the encroachment on its authority by medical science. Paré and other highly regarded physicians maligned him. They turned to prosthetics to help the maimed (Ring 1991).

Even before Tagliacozzi's death, the boundary between reconstructive surgery fact and myth was blurred. Others claimed that detached skin from the buttocks or from another person could be used in reconstructions, although there is no record that any of them tried such procedures. Tagliacozzi refuted these ideas in his textbook. Nevertheless, the myths persisted and were embellished over time. In 1710 the British Tatler claimed that “Tag'' had reconstructed the noses of three Spaniards with skin from another man's buttocks. When the skin donor was subsequently beaten, the new noses reportedly swelled in pain, forcing the Spaniards to protect their donor, who was said to have “led them by the nose.” The author also claimed that the incision sites on the donor itched when one of the reconstructed noses smelled pepper or other strong spice. In another case a reconstructed nose supposedly fell off when the skin donor died. Such foolishness took its toll. Updegraff concluded that “in the seventeenth and eighteenth centuries, the art of facial restoration was in such disrepute as to become almost forgotten” (1938, 650).

Although Tagliacozzi claimed to have improved earlier reconstructive techniques, German surgeon Eduard Zeis provided persuasive evidence to the contrary in his exhaustive 1863 history of what he had called “plastic surgery in his earlier 1838 book (Patterson 1977, 7–11). Nevertheless, Zeis acknowledged that Tagliacozzi, who today is regarded by most physicians as the father of plastic surgery, carried out a number of these operations and provided more detailed accounts of the techniques, including illustrations, than had anyone previously. Zeis found credible evidence of only four other practitioners in Europe who tried to reconstruct noses at the same time as Tagliacozzi or soon after him. However, he found no evidence of any European doing nose reconstruction in the second half of the seventeenth century.