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Evolution of Plastic Surgery in the United States Military

American Revolution (1775-1783)

Surgery in the American Colonies

  • Only 1 in 9 "doctors" had formal training
  • Surgeons distinct from and subordinate to physicians
  • No professors of surgery
  • No anesthesia

Colonel John Jones (1729-1791)

  • Colonial and Continental Army
  • Surgeon educated in colonies and Europe
  • First full professor of Surgery
  • Authored first manual of surgery (1775)

First Surgical Text in America

  • Plain, Concise, Practical Remarks on the Treatment of Wounds and Fractures
    • Always suture facial lacerations
    • Few sutures and remove as soon as possible
    • Stratification of burn wounds and treatment accordingly

American Civil War (1861-1865)

Chloroform for Anesthesia

  • Given on empty stomach
  • Pre-medicated with brandy

Rifle Injury Was Most Common

  • Union Army alone had 9,815 facial injuries
  • 4,914 soft tissue only without fracture

32 Reconstructive Procedures Performed

  • Primarily facial reconstruction
  • Increased collaboration across specialties

Private Carleton Burgan

  • B Company, Purnell's Maryland Legion, United States Army
  • Admitted to Hospital with Pneumonia
  • Given calomel (mercury chloride)
  • Apparently caused an ulcerative lesion at the roof of the mouth which enlarged and became infected

Dr. Gurdon Buck (1807-1877)

  • Auxiliary Corps, Volunteer Surgeons
  • MD from College of Physicians and Surgeons, NY
  • 18-month appointment at NY Hospital
  • 2.5 years studying in Europe
  • Surgeon, City Hospital in New York
  • Broad practice in fracture care, ENT, general and plastic surgery and urology

>5 Operations

  • Prosthetic to repair the oral cavity and loss of maxillary bone and afford "solid support to the soft parts"
  • Advancement flaps
  • Forehead flap

Dr. David Prince (1816-1889)

  • Surgeon, United States Army
  • Published book specifically on plastic surgery
  • Felt plastic surgery had no role in military medicine

Colonel Reed B. Bontecou (1824-1907)

  • Surgeon, 24th Infantry Regiment of the New York State Militia
  • Surgeon in Chief, Harewood U.S. Army General Hospital, Washington D.C.
  • Systematically photographed war wounded for future military surgeons

Summary

  • Start of reconstructive surgery in the U.S. military
    • Bringing multiple techniques to the injured soldier for purposes of reconstruction
  • Medical photography to document results and educate others
  • Codification of plastic surgery practice in at least two books

World War I (1914-1918)

Major Harold D. Gillies (1882-1960)

  • 1915 volunteered in France as a general surgeon
  • Learned from surgeons in theater about treating facial injuries (flaps, mandible fractures, etc.)
  • Established first military unit devoted to plastic surgery in Aldershot

Colonel Robert H. Ivy (1881-1974)

  • Born in England (1881)
  • Dental (1902) and Medical (1907) school at University of Pennsylvania
  • Works with Major Vilray Blair in SGs office coordinating care of maxillofacial injuries for U.S. military (1917)
  • WWI served as a surgeon at Base Hospital No. 115 in Vichy, France
  • Chief maxillofacial surgery, Walter Reed Army Medical Center (1919)
  • Importation of reconstructive surgery knowledge
  • U.S. military support and organization for the specialty

World War II (1939-1945)

  • Military now anticipates need for plastic surgery from the outset
  • LTC J. Barrett Brown serves as consultant
  • Establishment of U.S. military units
  • Efforts to standardize plastic surgery care

Captain Sterling Bunnell (1882-1957)

  • WWI: Surgeon, Base Hospital 47
  • Published "Repair of Tendons in the Fingers and Description of Two New Instruments"
  • MG Norman Kirk invites Sterling Bunnellto serve as consultant to the Army Surgeon General to "guide, integrate and develop the special field of hand surgery"
  • After touring Army Hospitals, felt the military was failing patients with hand injuries
    • Establishes 9 hospitals across U.S. focused on hand surgery
  • Patients with complicated hand injuries were funneled to these centers
  • Trains surgeons capable of treating all aspects of hand injury: soft tissue, orthopedic and neurological
  • Approximately 20,000 injured hands were treated in these hospitals

Korean War (1950-1953)

Pre-WW1

  • 1901-1910: Alexis Carrel describes vascular anastomoses
  • 1906: Goyanesperforms first arterial graft with popliteal vein
  • 1907: Lexerreplaces portion of axillary artery with saphenous vein

Post-WWII

  • 1948: Willis Potts develops atraumatic vascular clamps
  • 1948: Kunlinperforms femoral-popliteal bypass with saphenous vein

Arterial Repair

  • Limb salvage rates were low
  • DeBakeyreviewed results of arterial repair from WWII and determined they often failed leading to amputation
  • His research informed an Army doctrine of ligating the majority of arterial injuries
  • Facing high rates of amputation, Army surgeons attempted repair
  • Equipment limitations:
    • Only 2-0 and 3-0 silk suture available
    • Penrose drains used as atraumatic vascular clamps
    • Surgeons scavenging Japan while on R&R to procure more instruments

Limb Salvage

  • Summer 1951
    • First repair performed at the 8055th
    • Subsequently, 8076th started performed reversed saphenous vein graft repairs of damaged arteries
  • Captains Otto Apel and John Coleman
    • US Army, 8076th MASH
    • Started teaching others to perform vascular repairs
  • Amputation rate decreased to 13%with vascular repair compared to 40% in WWII

Vietnam War (1955-1975)

Air Evacuation

  • Helicopters used with success during Korean War for medical evacuation
  • Vietnam
    • Stronger, customized aircraft
    • Improved communications
  • Time from being wounded to treatment decreased from 4-6 hours in Korea to <1-hr

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