Aulus Cornelius Celsus (25 bc–50 ad) was probably not a physician, but a writer from a noble family and the author, in about 30 ad, of De Medicina (On Medicine) in eight volumes. In book seven, chapter nine, vessel ligature and lithotomy as well as lip closure (cleft lip or lip tumor) by means of flaps are reported. It explains how “defects of the ears, lips and nose can be cured” (curta in auribus, labrisque ac naribus, quomodo sarciri et curare possint), followed by a description of wound closure by advancement flap.¹⁰ “The defect should be converted into a square (in quadratum redigere). Then, from the inner angles transverse incisions are made (lineas transversas incidere), so that the part on one side is fully divided from that on the opposite side.” “After that, the tissues which have been undermined, are brought together” (in unum adducere). “If this is not possible two additional semilunar incisions are made at some distance from the original (ultra lineas, quas ante fecimus, alias duas lunatas et ad piagam conversas immittere), but only sectioning the outer skin. […] These latter incisions enable the parts to be easily brought together without using any traction” (Fig. 2.2). Celsus holds a key role in the history of plastic surgery, as he is considered the earliest writer on this topic. He is responsible for introducing the four cardinal signs of acute inflammation, “redness and swelling with heat and pain” (rubor et tumor, cum calore et dolore). A copy of Celsus’s manuscript was discovered in Milan in 1443, and printed for the first time in 1478 in Florence.¹¹ De Medicina went through more than 50 editions.

Fig. 2.2 Lip repair according to Celsus.

(Reproduced from Nélaton C, Ombredanne L. Les Autoplasties. Paris, Steinheil, 1907.)

Claudius Galen (c. 129–201 ad) was born in Pergamon (Turkey), studied medicine at the Asklepieion (see above) in his native city and moved to Rome. He wrote about head traumas, techniques of trephination for evacuating hematomas and various types of bandaging. An excellent anatomist, he described more than 300 muscles and seven pairs of cranial nerves and contributed to neurology, demonstrating that nerves arise from the brain or spinal cord. He observed that section of the laryngeal nerve resulted in dysphonia. For management of wounds he used sutures and cautery. Numerous works of Galen were lost, but 82 survived. Originally written in Greek, many were translated into Arabic and Latin. Galen’s Opera was first printed in Latin in Venice in 1490 and in Greek at Venice in 1525 by the Aldine Press.

Plastic surgery after the decline of the Roman Empire

Byzantine surgery

Oribasius (325–403 ad) wrote a collection of medical texts entitled Synagogae Medicae in which reconstructive procedures for cheek, nose, ears, and eyebrow defects are described.¹² Paulus of Aegina (625–690 ad), surgeon and obstetrician, was the author of a medical encyclopedia (Epitome) in seven volumes. In book 6, which deals with surgery, a description of tracheotomy, tonsillectomy, and lip repair is supplied.^13,¹⁴ “Defects [Greek, colobomata] of the lips and ears are treated in this way. First the skin is freed on the underside. Then the edges of the wound are brought together and the callosity is removed. Finally, stitches holding them into position are applied.” This technique closely resembles that of Celsus.

The Middle Ages

Arabian surgery

Arabian medical writers came from different nations, such as Persia, Syria, and Spain. Their only common denominator was the language. The most representative figure was Abū-l-Qāsim or Albucasis (c. 936–1013 ad), whose famous treatise, Al Tasrif (On Surgery), was translated into Latin and first published in 1500. It was the first independent surgical treatise ever written in detail. It included more than 200 illustrations of surgical instruments, such as tongue depressor, tooth extractor, hooks, and cauteries, most invented by Albucasis himself, with an explanation of their use.¹⁵ Like most Arabian surgeons, Albucasis was a proponent of cautery, for different clinical applications and the management of wounds and cleft lip. He was the first to use a syringe with a piston.

The rise of the universities

The founding of the universities is one of the most important events in the Middle Age and a key factor in the development of modern culture. Originally, universitas denoted an aggregation of masters (magistri), students, or both, and the primary goal was teaching philosophy and theology. Lessons were practiced in the house of the masters or in small rooms. Students sat on the floor, whereas the professor was in the chair. The oldest university, at least in Europe, was Bologna, established in 1088, followed by Paris, Oxford, and Montpellier. In Bologna medicine was taught and cadaver dissection was accepted, thus significantly contributing to the development of anatomy. Mondino de’ Luzzi (1270–1326) was the first anatomist to lecture directly in front of the cadaver (Fig. 2.3). As anatomists were also surgeons, such as Henry of Mondeville (1260–1320) or Guy of Chauliac (1300–1368), surgery was part of the teaching of anatomy.

Fig. 2.3 Mondino in the chair supervising a cadaver dissection.

(Reproduced from Ketham J. Fasciculo de Medicina. Venice, Gregorio de’ Gregorii, 1493.)

The discovery of printing

The invention of printing around 1440 by Gutenberg spread medical knowledge and considerably enlarged the libraries of universities and monasteries.

The first printed textbook on surgery was La Ciroxia (On Surgery), by William of Saliceto (1210–1277), issued in Venice in 1474. This text has particular relevance in the history of surgery, because it reintroduced the use of the surgical knife to replace cautery, strongly advocated by Arabian surgeons. The first printed textbook on anatomy was Anatomia by Mondino de’ Luzzi, issued in Padua about 1476, which remained the reference text for numerous years. The printed works of Hippocrates, Galen, Celsus and Arabian writers served to educate medical students.

The Renaissance

Renaissance surgery

One of the greatest surgical figures of the Renaissance was the Frenchman Ambroise Paré (1510–1590) (Fig. 2.4). A humble but very talented barber surgeon, Paré amassed considerable experience from his tireless work in the battlefields. He disputed the common belief that gunshot wounds were poisoned and required the barbaric practice of wound-cleansing using hot cautery or pouring boiling oil into the wound. He applied a paste of egg yolk instead, mixed with oil of roses and turpentine, to patients’ great relief. In 1545, he published a treatise on gunshot wounds, demonstrating that the use of cautery was unnecessary (La méthode de traicter les playes). He wrote extensively on surgery and his works are collected in Les Oeuvres, published in 1575.¹⁶ To demonstrate relationships between anatomy and surgery, he borrowed images from De Humani Corporis Fabrica, issued a few years earlier, in 1543, by Andreas Vesalius (1514–1564). He sutured cleft lip, whereas he closed the cleft of the palate using obturators (Fig. 2.5). To approximate scars he stitched adhesive on the outside of the wound margins (Fig. 2.6), and supported Tagliacozzi’s work on nasal reconstruction.

Fig. 2.4 Portrait of Ambroise Paré (1510–1590).

Fig. 2.5 Cleft lip repair.

(Reproduced from Paré A. Les Oeuvres. Paris: Buon, 1575.)

Fig. 2.6 Facial wound suture. A piece of linen is stitched to the skin to facilitate wound edge approximation.

(Reproduced from Paré A. Les Oeuvres. Paris: Buon, 1575.)

Nasal reconstruction in the western world

In the western world the first attempt to restore the nasal pyramid dates back to the first half of the 15th century. It was performed by members of the Branca family from Catania (Sicily). Gustavo (early 15th century) used skin taken from the cheek. His son, Antonio, made considerable improvements to the operation. He selected the arm as the donor site, to avoid further scars on the face. About 1460, at Antonio’s death, the Branca method, which was kept as a family secret and passed on by word of mouth, was discontinued in Sicily.

In the late 15th century, nasal reconstruction was resumed by Vincenzo Vianeo in Calabria (southern Italy). His sons Pietro (about 1510–1571) and Paolo (about 1505–1560) established a flourishing clinic for rhinoplasty in Tropea (Calabria). Evidence of their reconstructive work comes from the Bolognese army surgeon Leonardo Fioravanti (1517–1588) (Fig. 2.7), who assisted in Vianeo’s operations and published an accurate report in Il Tesoro della Vita Humana (Treasure of Human Life) issued in Venice in 1570.¹⁷

Fig. 2.7 Portrait of Leonardo Fioravanti (1517–1588), who was the first to describe the arm flap procedure for nasal reconstruction.

(Reproduced from Fioravanti L. Il Tesoro della Vita Humana. Venice: Sessa, 1570.)

I moved to Tropea where at that time there were two brothers Pietro and Paolo, who made a nose for anyone who had lost his by some accident […]. I went every day to the house of these surgeons, who had five noses scheduled for repair and when they wanted to perform these operations they called me to watch and I, pretending I had not the courage to look at, I turned my face away, yet my eyes saw perfectly. Thus, I observed the whole secret from top to toe, and learned it.

Then follows the description of the arm flap procedure.

Possibly Fioravanti’s book came under the eyes of Gaspare Tagliacozzi (1544–1599) from Bologna, Professor of Surgery at Bologna University, who successfully applied the technique on some patients. In 1597, he published in Venice a textbook De Curtorum Chirurgia per Insitionem (On the Surgery of Injuries by Grafting),^1,¹⁸ in which the nasal reconstruction operation is shown step by step and skillfully illustrated. The instruments necessary for the operation are presented first, followed by the indications, flap outlined on the arm, flap inset, the bandage necessary to secure the arm into position, flap severed, trimmed, outcome of nasal repair, as well as different clinical applications for lip and ear (Fig. 2.8). The book was well received and was reprinted in a pocket edition at Frankfurt the following year, directed specifically at military surgeons who were often confronted with the problems of nasal repair in the battlefields.