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Redefining Plastic Surgery

Chandra, Ramesh MS, MS, FRCS; Agarwal, Rajiv MCH, FRCSEng, FACS, FRCSEd; Agarwal, Devisha MBBS Scholar

Plastic and Reconstructive Surgery – Global Open: May 2016 - Volume 4 - Issue 5 - p e706
doi: 10.1097/GOX.0000000000000659

From the *Post Graduate Department of Plastic Surgery, King George’s Medical College, Lucknow, Uttar Pradesh, India; Department of Plastic Surgery and Burns, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India; and G.S.V.M Medical College, Kanpur, Uttar Pradesh, India.

Received for publication September 21, 2015; accepted October 2, 2015.

Presented at 13th Annual National Conference of the Indian Society of Cleft Lip, Cleft Palate and Craniofacial Anomalies, India, February 14–16, 2014, Lucknow, India; and 49th Annual Conference of Association of Plastic Surgeons of India, October 2014, Chandigarh, India.

Disclosure: The study is self funded. The authors have no financial interest to declare in relation to the content of this article.

Rajiv Agarwal, MCh, FRCSEng, FACS, FRCSEd, Department of Plastic Surgery and Burns, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Plastic surgery is one of the most ancient forms of surgery, and its roots can be traced back to the time of Sushruta, the father of surgery (600 BC),1 who is credited with performing the first ever reported plastic surgical procedures. The name, however, defies a clear understanding and an appropriate definition that could cover the entire scope of activities performed at the present moment. An extensive search of the plastic surgery literature was performed to find out the best available definition, but a comprehensive definition could not be found. This led the authors to explore the modern and ancient literature, including the thousand-year-old sacrosanct Indian epics, Gita, and Vedas in their quest to redefine plastic surgery. This review of the age-old fundamental secrets of life made it possible for us to extract the coveted relevant information to redefine plastic surgery, which is being presented in this article.

The term “plastique” was first used by a French anatomist and surgeon, Desault in 1798.2 The word “Plastic” is derived from the Greek word “Plastikos,” which means the ability to mold tissues. The procedures were being performed on body parts from the head to the toes. However, the term “Plastic” was first incorporated by von Graefe3 in his monograph “Rhinoplastik” published in 1818. The term “Plastic Surgery” was used by Zeis4 of Germany as part of the title of his classical work Handbuch der plastischen Chirurgie published in 1838, and the term thereafter became popularized.

Davis,5 in his book Plastic Surgery—Its Principles and Practice, defined the scope of plastic surgery from “top of the head to the sole of the foot.” Gillies,6 in his book Plastic Surgery of the Face, laid down 16 principles of plastic surgery to be followed. He defined reconstructive surgery as an attempt to restore the individual to normal and aesthetic surgery as an attempt to surpass the normal.

Esser,7 a Dutch surgeon, pointed out that “plastic” was a poor term that did not define the specialty and that the term “Structive” derived from the Latin word “structo” (I build) was more appropriate, and it was adopted to be used for the European Journal in December 1936.

McGregor,8 in his book on the fundamental technique of plastic surgery, has very clearly expressed his view about the use of eponyms because they lack precise meaning and are liable to cause confusion as they have different meaning in different countries.

Converse (1964) stated that “Plastic Surgery is a specialized branch of surgery devoted to the treatment of the deformities of the face and other areas of the body, notably the hands. Because of the special nature of plastic surgery, it is largely concerned with form, as is implied in the term plastic.” The scope of plastic surgery kept on continuously expanding ever since then, and many new techniques such as microvascular surgery, craniofacial surgery, endoscopy, lasers, distraction osteogenesis, transplantation, implantations, and reimplantations were introduced in the sixties and seventies. This definition hence fell short of its range and spectrum, and a need for revision was felt.9

In 1965, Manekshaw, an Indian plastic surgeon, in his book Plastic Surgery in the Tropics, ratified Gillies’ definition that “Reconstructive surgery is an attempt to return the tissues to normal. Cosmetic Surgery is an attempt to surpass the normal.” The definition implies a lot, but the scope and spectrum of activities covered by the definition are difficult for students and beginners in the field of plastic surgery to comprehend.10

Aufricht (1972) stated that “Plastic Surgery like all forms of surgery is besides a science, a manual art and craft.” The qualifying statement adds grace to the specialty and gives a distinct status to the surgeons, but it gives no idea of its scope to the general practitioners and the medical students.11

Barron and Saad (1980) opined that plastic and reconstructive surgery has no anatomical or systemic boundaries and in essence is the “study of anatomical defects and disabilities.” The definition acknowledges the broad spectrum of activities of the specialty, but no specific details can be grasped mentally about the organs and organ systems to be treated.12

Jurkiewicz et al (1990) proposed a conceptual definition, “Plastic Surgery brings back, refashions and restores 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.” This definition covers restoration of anatomy of the part destroyed by chance, but the scope of activities is difficult for students and beginners to mentally visualize and realize.13

McCarthy (1990) defined plastic surgery as a “problem solving specialty” and that the plastic surgeon helps other surgical specialists when dealing with tissue defects. This definition again does not encompass the whole spectrum of activities being performed in plastic surgery in general.14

Mathes (2006)15 again professed that plastic surgery is a problem-solving specialty where the plastic surgeons treat skin and its contents with no anatomical boundaries.

Thorne (2012),16 in Grabb and Smith’s Plastic Surgery, defines “Plastic Surgery as a unique specialty that defies definition, has no organ system of its own, is based on principles rather than specific procedures and because of the cosmetic surgery is the darling of media–No complete definition exists.” This definition is a very broad generalization. It is an equally mystifying statement about the activities being done by the plastic surgeons best understood by themselves but not by their colleagues in allied specialties. Neligan (2013)17 defines plastic surgery as the last real general surgery and the plastic surgeon as the last real general surgeon.

Thus, a review of literature revealed that a complete and comprehensive definition was lacking. The plastic surgeons have a moral obligation for documenting a suitable definition.

Thorne’s definition in the textbook Grabb and Smith’s Plastic Surgery was subjected to a critical evaluation to find out how an organ is defined. An organ is defined as a part of the body composed of 2 or more tissue types and performing 1 or more specific functions. The organs are further classified into external and internal organs. Plastic surgery deals most commonly with external organs: the eyes, ears, nose, mouth, skin, hand, feet, and all body openings, which are controlled by respective organs. Therefore, we do not accept the statement that there is no organ system for plastic surgery as mentioned in this definition.16

The earlier definition by Davies8 that plastic surgery extends from top of the head to the toes is a very correct statement because we deal most of the time with external organs spread all over from the top of head to the foot. The biggest lacuna in our understanding was that the organs being treated by us could not be classified as a distinct group, and this semantic dilemma remained unsolved.

The ancient Indian texts written some 5050 years ago contain the essentials and values of all aspects of life and even the medical science that stand true even to this date. The sacred text “Bhagvat Gita” is a quintessence of the Vedas enunciated by the Almighty at the beginning of the creation of the Universe.18

The authors came across relevant verses in the Gita, which are based on pure scientific knowledge of anatomy and physiology that existed at that time. The human body has 9 gates consisting of paired eyes, ears, nostrils, and a mouth, all located in the head, while the organs of reproduction and defecation are situated in the lower part of the trunk. In females, there are 3 additional passages, the reproductive passage and a pair of nipples for the excretion of milk. Totally there are 12 external passages in females. All the passages are connected to the respective organs.19 The plastic surgeon is dealing with these passages and thus correcting the functions and the appearances of all these organs within the body.

The human body is a congregation of organ systems, pathways, and interconnections, which perform all their personal, social, and worldly activities from day 1 until the last day through 5 organs of perception and 5 organs of action regulated by a super control mechanism of mind, intellect, and soul.20

The 5 organs of perception, called sense organs, known as Gyanendriya,21 are eyes, ears, nose, tongue, and skin. The 5 organs of actions, known as Karmendriya, are mouth (larynx), hands, feet, organs of reproduction, and organs of defecation. The plastic surgeons are directly involved in performing surgery on these organs. The impact of these 2 verses on our mind was thrilling, and a eureka like feeling was there. These verses gave us the coveted information, which we have been postulating and we consider it as a gift to us for the new definition.

The verses provided us with the information regarding the use of the nomenclature for the group headings of the 19 organs in males and 22 organs in females whom we have been treating. These organs of perception and organs of action are distributed all over from the top of the head to the soles of the feet. All of these are external organs on which plastic surgical activities are performed. Thus, we have been able to find that an organ system exists.

The plastic surgeons need to adopt this terminology in the new definition, so that whenever somebody is asked to define plastic surgery, the answer should be universally the same and there should be no ambiguity as it exists today. The definition should be able to cover and assign all the chapters in our books to one organ or the other. In other words, the entire scope of plastic surgery should be covered by the new definition.

The latest textbook of plastic surgery17 has 6 volumes and 199 chapters. The draft of the new definition devised by the authors was able to cover 191 chapters, which could be assigned to 1 organ or the other except chapters on innovation, implantation, transplantation, and replantation. Therefore, it was decided to include these exceptions in the new definition.

Hence, we propose a new definition of plastic surgery, which covers the entire scope of this specialty as discussed earlier. “Plastic surgery is a specialized branch of surgery, which deals with deformities, defects and abnormalities of the organs of perception, organs of action and the organs guarding the external passages, besides innovation, implantation, replantation and transplantation of tissues, and aims at restoring and improving their form, function and the esthetic appearances.”

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A new definition for plastic surgery based on the organ system has been devised. A review of literature of existing definitions was done, and the need for a new definition was felt keeping in view the vast scope of the specialty.

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The authors gratefully acknowledge the help of Dr. Mrs. Padam K. Agarwal and Dr. Mrs. Preeti Sinha in providing technical inputs and insights into ancient literature search and reviewing this manuscript.

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Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.