CONTRIBUTIONS TO PLASTIC SURGERY DEVELOPED AT THE UNIVERSITY OF MIAMI SCHOOL OF MEDICINE 1956-1996
Introduction
through the Korean War- Early Years at University of Miami/Jackson Memorial Hospital
- Cleft Palate
Introduction Through the Korean War
Today, I want to tell you a little bit about what plastic surgery is, and what we have done here specifically at the University.
As a student at Harvard, I rotated through pediatric surgery and in my third year, which was 1943, that is more than fifty years ago, I saw these children with cleft lips. I had never seen a cleft before, had no idea what it was, and it was so horrible that I was touched. You see normal eyes, and then they smile and you see their adenoids. So I began to study to see what had been done and what could be done, and I found that the first history of clefts was in the Tsin Dynasty 290 A.D. But by the middle ages, Ambroise Pare was pushing a darning needle through the edges of the cleft and then wrapping a figure eight thread around it to get it to grow together, after he had cauterized the edges.
From that, I decided to go everywhere that I could to learn about clefts. It became my hobby, not my work. I went to England and up to the Lord Trealor Hospital in Alton, north of Oxford. There was Professor Kilner, who did a very careful first straight-line closure, and it was as good as anybody was doing at that time, but it wasn't what we really were looking for. Back in Basingstoke, where I was training and living, they let me do a few. This is one of the ones I did with a straight-line closure. I was horrified at the result, because if you consider the ideal beautiful "normal", which is always our goal, that was far short.
I had gone to England to study with Sir Harold Gillies, who is this man rubbing his head. That head was a great brain. At first I arrived there memorizing all the books that had been written on plastic surgery up to that time, and there weren't very many. He used to tear me to ribbons when I would try to say for a case. He would say, "What would you do for a case?" I would say, "Well now in chapter so-and-so you would find this work," and he would just rip me up. Then I realized slowly and gradually.
To show you how he started out in the First World War, a pilot, looking like that above, ended up like that when they put fire on their aircraft. This was the sort of work he had to start with, and you could imagine what Herculean problems he faced. As I stood at his feet and tried to fight off his attacks, I began to pick up little home spun statements that really were the basis of all of life and plastic surgery and everything else. I put them as the ten commandments first. And this was published in 1950. Then I finished my year with him, and I went back to St. Louis. I was looking again for answers to this cleft problem.
I got to St. Louis where the best American plastic surgery in clefts was being done. The measure on the left was a French man who designed a method that was modified by Dr. Blair in St. Louis, and then Dr. James Barrett Brown modified that. That was the method they were using at the time in St. Louis. It was a great improvement over the straight-line closure, but it still didn't have the answer. They did it by the A to A' markings. Nobody thought about it; it was just a memorized technique. They faced it and did it and I was very much against that, so they discontinued my time there fairly early.
I went from there up to the Straith Clinic in Detroit and then on to LeMesurier, who had figured out a way to make an artificial cupid's bow. And it was rather exciting. Hagedorn, a German, had described it many years before, but LeMesurier gave his modification and it eclipsed all other methods up to that time. So, I was traveling trying to learn and see what each one did and finding fault at certain cases.
Then the opportunity came to go back to England and write a book with Sir Harold. Now can you imagine the opportunity that gave … unless you know Sir Harold. When I first said I would do it, I said, "Now how long do you think it will take, three or six months? If you get your secretary to get all the material together, I will just drop in and we will put it together." He said, "You had better plan on six months, boy." I arrived and it was eight before he started to help me. We would work in the bookery. It was after about ten months when we got him into the bookery. It took us two years.
This was the sort of thing I would say: "We are going to start at ten and we will go to work on the book." I had to get the stuff out of him, because he knew it all from two wars, and the in between, and I wanted to get this. The only problem was, every time we planned to do something, he would find something else to do. Now, he loved to chase this dog around and try to catch him. Or Lady Gillies would set it up so we would go looking for wild flowers, or at night, when we'd get some real work done, we'd go looking for the nightingale, and then we would sit for a damn hour waiting for the damn nightingale to sing. When he got through singing, I would say, "Sir can we go back now and go to work?" He would say, "Oh boy, don't be in a hurry." This went on for two years, but we got the book done.
Here is a case from the First World War. This is Private Bell. He got blown out in the trench -- gun shot -- and Sir Charles Villatee, a dentist in Paris, an American, pulled it all together and then sent the patient to Gillies and said, "Isn't this great?" Gillies took one look at it and said, "My God, this is atrocious." He took it all apart, and it sprang open, and a principle was born: Find what is normal, move it into normal position, and retain it there. Then with local flaps, Gillies made a face. That was during the First World War, in the early days, and the early principles were being laid down. When we finished the book two years later, I carried it on my shoulders to the Queen Elizabeth and climbed on. Gillies waved goodbye.
The publishers … we didn't know who we were going to get, they had all turned us down because it was a very unusual book. I took it to Little, Brown and they said, "Give us a little while. Let us look it over." They let Brad Cannon, a very serious friend of Dr. Brown's in Boston, look at it. After they looked the book over, Ted Phillips called me from Boston and said, "We let Brad Cannon look it over, and he said if you publish this book you'll set plastic surgery back fifty years." And then he said, "We are going to take it." I said, "Well, thank God." They did, and it was a very popular book for many years. So, Gillies was waving good-bye hoping we could find a publisher.
When I got back from England they had been chasing me. I had served in the Second World War and they wanted me for Korea. So I volunteered, and I got the best appointment at the San Diego Naval Hospital. They had eight hundred plastic surgery problems going through a year, and that was just heaven. But they put me down in the outpatient doing rectals on pregnancies. Now that is typical, isn't it? I mean I have just finished a book with Gillies on reconstruction of the wounded of the war, and we were even doing some from the First World War. And I am down doing rectals on pregnancies! Well, I raised so much cain that they finally, without giving me a layover in Waikiki, they got me right out to Korea with the Marines.
My last two days, when we had time off before we went to Korea, I went up to Los Angeles to a bachelor's ball. That is where I found Barbara. We will get back to that later. That is the best story of all, but I can't do that here.
This was our commando training. This is Korea, 1st Marine Division, the camp. If you will notice, there is a tent on the far right at the bottom. That is where we made our little clinic eventually. If you go up three layers, you see that long row of tents. That is where we slept. We were in the second from the left at the top, in that tent. I saw a lot of patients with clefts out in the bush and in the little cabins, where we would go through with the jeeps. I got some pictures, and I put them up on a board like this and studied them night and day because I had nothing else to do.
One day, I woke up and looked at a picture at an angle where I could see there was a cupid's bow, and there had been one there all along, and of course that made the whole thing. Because, everybody had been cutting it off and sewing up, and this goes back to 290 A.D. That day I realized what we had, so on an orange crate I drew a diagram of what we should do. And what is the principle? Find the normal, return it to normal position, and retain it there. That is the principle that I got from Gillies with his work in the war. You can apply it, and you can apply it to every other thing, and that is what the residents had been learning over and over, this application of principle.
This was the first case. We had to catch him and, without parental permission, we fixed him and then turned him loose, and then they began to come in all over the place, in the A-frames and all. The little boy on the left … I will show you the result to show you that we were making a cupid's bow. This was a clinic that we developed out there of all sorts of problems. You see the boy standing there that I am holding on to? That is elephant boy with a trunk I hooked on for other work. Behind him is a North Korean who had been burned by our people, and then he had sneaked across because he had heard about the reconstruction work going on in Korea at the 1st Marine. So he sneaked across at night and came in and we put him in the thing. Even though we knew he was North Korean we went ahead and did him along with all the others. But, a line officer came by one day seeing this group. Seeing all these pedicles hanging off in all directions, he said: "Doc, if you will give me a platoon of these, I will set them loose north of the enemy and we will never even see another communist."
During my time out there, I was interested in requests to change the oriental and the occidental features. I had a little fun with that, but I haven't found much use for that anymore. But once in awhile there is one done.
I got back to the United States, came to Jackson Memorial Hospital and tried my best to get Lepps. I was so anxious to get him, but we couldn't. We found this little baby in a trailer camp near by, and we got him in and did him, and that was my first case in America. Then, in order to try to get other cases, because I couldn't get in to the Cleft Palate Clinic, it's a political thing, I volunteered to be a consultant with the Navy. I went down to Key West and found this little boy, and we fixed him, and I remember this so well because it was on one of these visits that Kennedy was killed in '63. We were beginning to get a few cases, but I started going to the islands to get more because I wasn't getting as many as I had hoped to. We did 52 trips to Jamaica because I had a good friend who ran that unit down there, and they got us everything you could imagine. Then there was a trip to Haiti over to the Mellon Hospital at Albert Schweitzer. They collected 23 cases which we did in a couple of days, running two rooms with anesthesia. We did about 12 clefts. Here is a group before the surgery and here they are, half of them throwing up or whatever, after the surgery and the anesthesia. This was the way we were able to do the work and develop the method and then come back and go on with it.
Barbara was over on the beach one day, and she saw this boy who was seven feet tall riding his bicycle delivering papers. She asked her friend on La Gorce Island about this and was informed that when he delivered papers all the kids would run into the house and slam the doors because he was such a monstrosity. As it turned out, this is craniometaphyseal dysplasia, which was first acknowledged and published in Egypt. It involves overgrowth of the bone. He was seven feet tall, riding a bicycle with an overgrown head. We took him in, and the bone was so hard it broke all of our chisels and drills and our saws, but we shaved him down to this. Afterwards he asked if I would back a loan, and he started a company, got married to a very attractive nice girl, had normal children and has been doing extremely well. Chuck Graham was the one who got the priest to get the people in the La Gorce Island to contribute so that they could pay for the hospital privileges for the time that he had to be in, and he had to be in quite a long time because of the long surgery. That was the first operation on craniometaphyseal dysplasia ever.
This was his sister, whose head was so heavy she couldn't stand or sit up, and her eyes bulged out from her head. I had seen Gillies bring the jaw forward. In this case, it looked like we would have to go from behind and cut out the bone in the back and bring the orbits back, which we did with Basil Yates, the neurosurgeon, who helped me keep from getting the chiasma. We got her greatly improved. Unfortunately, we didn't know that she had stopped breathing. As it turned out her foramen magnum, the hole which the spinal cord goes through, was so small that with the surgery and the edema it closed off her breathing and we lost her. But she had no future other than this. In the publication, I warned others that if they ever do this, look out for the foramen magnum because that is a killer in the case.
Now I am going to go to what most people think of as plastic surgery, and the whole purpose is not usually to save a life in plastic surgery. It's to raise the standard and improve the quality of life. That is what it is. This young girl above looked better with a little reduction, and we've added some work to that. This is a chin implant; here is another one. Here at the University we first began augmentation of the tip with cartilage grafts, which later became a fad throughout the whole world and was overdone. Now they are drawing back and doing it only occasionally, which is the way it should be done. This girl was the first one that we did. That was in 1963. Where we see the most problem is where there are so many people who are not trained to do this work doing it. The secondary work is much more … I do much more of that than I do primary. This is an example of a secondary case that has to have primary work. We also did some work on the face by concentrating on the neck and taking out the fat and this stuff, which was of interest, and we changed the approach a bit on that.
While in England with Gillies, I had seen these attempts at delayed correction of the jaw in the wounded soldiers, sailors, marines, and air force, and they were horrible. Gillies, who really knew what he was doing, couldn't get good results. I began to realize the reason for this was that when you break the integrity of the mandible and leave it for any length of time, which they had to do when they brought them back from the front, during that time the muscles of mastication contract and freeze, and there is no way to get the mandible out and in any kind of functional position. So the obvious answer was to put a bone graft in immediately. Now you can't do that in the war unless you have special circumstances, but in these ablation cases you can.
So I joined the ablation team, which was John Fomon, Dembrow, Ryan Chandler, and I was the plastic surgeon. I had the opportunity to catch the patients early and reconstruct them. We stopped this Andy Gump drooling, mumbling, and miserable condition of the oral cripple with the immediate graft. That just shows the defect following the incision of the cancer in the floor of the mouth. This shows the defect; I'll get over that quickly cause it is a little bloody. I took the total forehead based on the ear, brought it down and covered the new bone graft, covered the skin graft over the forehead, and he could eat everything but corn on the cob. This changed it for awhile. Then later they began to give the 6000R to all patients to increase their chances of living a long time, so we had to stop the work. But since then, microvascular surgery has done what this has done. It takes longer than it took us, but it is much better because you don't have to take the forehead. You can get a vascularized bone graft in there, and you don't have to have Andy Gumps anymore. We were the ones that started the work on that.
Being in the tumor clinic, I could get these kinds of cases. Now this case is a problem. This is a total nose missing from cancer and nobody had ever been able to build a nose that looked anywhere near normal and breathe. I went into the lab and worked it out with engineering, and we found that we needed to make a fulcrum for a cantilever to support the nose. That's the forming of that with a cross underneath this, and then locking this to the bone. We had a support now to make a nose. Then we could bring the forehead down on the nose in the old fashion way. Forehead flaps had been used since 600 B.C., but these were made with nostrils formed and all. We brought it down and then put it back and brought the forehead around, and you see he can breathe. It's delicate, and it's the first reconstruction of a total nose. We went on and did others later, but this showed the importance of not only lining and color, but the support to the nose.
Now we come to another problem that we had been seeing. Everybody had been looking at it, but nobody had seen the fact that these noses, cut off like this for cancer, have a septum hidden. If you bring it out in this fashion, you can make a beautiful platform without the bone graft. Then you can bring the flap down on that. If you make the nostrils on the forehead first and you put expanders in the forehead, you can get the forehead closed nicely. Then you can go ahead and make a nose. She can breathe with this nose, and I hear from her every year. We can make it delicate and life-like and all, because we used that septum which is very thin and very strong and very dependable.
Trauma - half a nose. Half a nose is sometimes harder than a whole nose, because you've got to compare it with the other half, which is normal. This girl was done. It is just the same approach with a little different modification, but developed here. And then another that left the cancer a long time. That had to be cleared up. Dr. Menn cleared it up, if you remember Dr. Menn, who was such a great dermatologist. Then we did the same approach on her and got her with her forehead and all with the expanders.
I want to take a minute on the cocaine nose. Through the ages the nose has been the attack of disease, such as leprosy and syphilis and now cocaine. And they all do the same thing; they burn out the mucosa that covers the support to the nose. If you burn that out, then the nose cartilage, in the septum and other areas, gets infected, dissolves and the nose gradually shrinks and disappears. The way to treat this is to bring back the lining that has been lost, and then you can put in support afterwards. This is a reconstruction after a flap that was developed here, taking cheek, denuding epithelium, and sliding it through, and bringing it inside, and then reconstructing the nose all inside, and then putting in struts to correct it.
Man's inhumanity to man This fellow was a policeman, who accidentally blew his nose off. Then he had eleven operations by people who supposedly think they know plastic surgery. His forehead and both nasal label cheek flaps are all in this mess. I am working on him now, but I would have much rather had him with the nose blown off than what we have to do now. This has all been published on how to do the support. It's all published. It's all right over there. And they don't use it. So, what are you going to do?
Besides doing just what comes to plastic surgery, I joined a team and got very great opportunities. Then there were other ways. Marc Rowe was a pediatric surgeon down here before he went up to the University of Pittsburgh. He was a friend and one day I went in and said, "Have you got anything that plastic surgery could help you with?" and he said, "Yes, the high imperforated anus is a terrible problem in certain cases. They get mucosal ectropion, rectal prolapse, wet bottom, and anal stricture." I thought that was pretty good, so let's look at it. Here is one. That's pretty difficult to live with. And so I designed an inferior hemorrhoidal flap. What was missing was an anal skin lining. That was all. We had to get that in there some way, and it had to be a flap because it needed viability. So we designed a flap. Then we made a little trapdoor flap that dropped in to stop the stricture. We wrapped it in that way and the patient was back to near normal.
Since then Dr. Pena has changed the original operation, and there is not too much use for this any more. Once in a long while it might be of value, but still it's there if it is needed. Another problem is when bone is exposed -- large areas of bone. It is hard to get a graft to grow on bone. So we developed the Crane principle here, where you move a flap and put it on the raw bone area and leave it for seven days and then shave off the flap, leaving just a thin curtain of soft tissue. You wait another two days and it will take a graft. You don't have to waste the flap; you put the flap back. That is the result of that raw bone with the flap put off and the skin graft put on.
Another good example for this was in hands, worse injuries than this where the joints were exposed, and so forth. You could put a flap on the hand for one week, take it off, shave, but just leave it very thin so you could have a normal looking hand afterwards, instead of the big fat pudgy hands you would see with flaps. Then put a skin graft on it. As you can see down here, the graft is taking well and it has definition and so forth.
The third way to get in on other specialties is to get them to let you do it in an emergency situation. In 1966, a pediatric surgeon excised a large omphalocele and closed it directly. It was just too big to close and it pushed all the abdominal contents against the diaphragm, which imposed on the lung. The compliance was so bad that the child was not breathing. The edges of the flap were white, and there was no hope for this child at all. They called me in late in the day. I took out all the stitches, and I didn't know what to do. They had already made relaxing incisions laterally, so there was no way to rotate a flap. I thought maybe a split graft would take to the edges of the wound, and who knows what would happen to the middle part. It might just be nourished by the fluid of the peritoneal cavity. I didn't know. So I tried it. The child died for the lack of being able to breathe. I couldn't get the graft off; it was stuck so well.
I thought we better go check this out. We went into the lab and removed a full thickness of abdominal wall. We tried one graft, and two grafts, and got lovely takes of the graft with no trouble at all. When we opened it up, we found that the omentum, the liver, the bowel were all floating up to the skin graft and giving its blood supply. This made it obvious that we didn't have to worry anymore. If you can't get the wound closed, there is too much tension, or there's a problem, put a skin graft over it and it will be okay. This is in a dog, and it covered it beautifully, and there was no trouble. We got it out easily afterward. You just lift it up.
Here is a fellow we were able to do. Barney Barrett and Bill Riley did this fellow. He was moribund and dying from gunshot wound. Terrible infection, peritonitis everywhere, and I asked them if I could go ahead and just put a skin graft over it, and it saved his life. A year or two later we wanted to take it out. I asked him if we could take it out and clean it out and fix him up. He said, "No," his compensation might be interfered with. So he wouldn't do it. Stephan Baker published five cases. I was on the paper with him, but he did the work of closing the abdomen after the skin graft had saved the life. It is interesting that two weeks ago at the University of Pittsburgh, the Grand Rounds I attended and spoke at, the whole Grand Rounds was devoted to getting the skin graft off and reconstructing the abdominal wall. Nobody knew how they knew to do the skin graft in the first place. So I happened to have a few slides.
Another way we've been able to help with the other specialties has been in reconstruction. Now, Gillies was first to know (Gillies is the grand man that I've talk to you about a lot). He developed the tube pedicle, and that is a story all its own. I learned to make a tube pedicle from him, and that was a good way to reconstruct. There is a tube pedicle made from the abdomen. You see she can spare it perfectly well. You watch her. We will swing it up. Now you see the abdomen has been reduced, but it is not too bad. You can cover that up easily. Here is her final result with reconstruction. That took awhile, and so when Jurkiewicz and others developed the musculocutaneous flap, we went to the latissimus dorsi and this was our modification of their design. Here it has been put in a two-stage deal, and saved all that long time with a reasonably good result. Then Hartrampf, in Atlanta, developed the rectus muscle to carry the pedicle. That took it from the same area we were taking the tube, but did it so much quicker that it's a far better way.
There was nobody doing reconstruction of the breast until we started down here with the tube pedicle. Now it's being done everywhere and being done beautifully, but that's the Hartrampf approach, which is a very good approach.
Now we will go back to my hobby for a little bit. We were able to take a case like this and get her reasonably good. But she is eighteen years old, and they suffer so all those years that I was determined … some way … if we could figure some way to cut this time. We had to figure out how to carry out the embryogenesis, to figure out what embryology would have done and how we could carry it out. Victor Veau was the first to say this in about 1930, but he was never able to follow it through. But as things developed, we had been able to do it. I'll show you what has been happening.
Ralph Latham was an orthodontist trained in Liverpool. He had gotten with Georgiade at Duke and then he had left there. There had been some problem or something and he went up to Ontario, Canada. He called me one day and said, "I have a case and I want to show you something that I think you will be interested in." I said, "Well give me a general idea what you are talking about," and he told me. I said, "I've got a case down here. Come on." So he brought one and we took the two and we started with his design of an instrument that would move the maxillary elements into a normal position - Principle. Then after getting them in normal position, we fixed them with a periosteoplasty, which locked them in and let bone come in and made it much easier for Dr. Wolfe not to have to do bone grafts. It supplied a platform which was even and solid and growing. That's what we had been dreaming of, because now you can go ahead and fix the lip and the nose, and if it is sitting on a normal platform it should stay that way. Before, in the bad position, it is a house sitting on the side of a hill. It is not going to work. Anyway, that is the new design. We move the elements all into position, and it looks a little fancy, but that's the corrected with everything corrected.
I'll show you a few cases with the Latham appliance, the periosteoplasty, and then the early work with the lip and the nose. You see how the dental arch is corrected, and the teeth are pretty good and the nose is improved, and the cupid's bow is coming down and the lips are fairly normal looking. This is the epitome, because here you are in two operations. At the age of two, we've done it all, except maybe some tiny lip or nose work later if it doesn't heal perfectly or the scars aren't the best.
Bringing Latham down, I had hoped that the dental department here would grab him and make him a member here. He wanted to do that. They wouldn't do it. We needed funds to bring him, and he came every three months for years. During that period, Rose Quick and the Soroptimist Club of South Florida financed it, brought him down, saw that he got reimbursed, where it was necessary, and even to this day we take care of all indigent patients' dental work through Rose Quick and her group. She is sitting in the second row there. We really appreciate it, and we continue to do this. Now we've got it where at the age of two, instead of the age of eighteen. This is just a little fun, because this is a child I did, a little girl I did, and she came in twenty years later, just the other day, to tell me that she was modeling for Versace.
Now a little bit about secondaries in the unilateral. I am going to show you a bit of bilateral, because that is more difficult. Here is a girl done by the old Mirault/Blair technique. You see the triangle scar, the flat lip, and the nose is a very small nostril. I had to take an ear to put into the nose, and I had to take a flap from the middle of the lip. That was a method developed here. I will try to show you. My hero was Dr. Bill Ray Blair of St. Louis. He was really the beginning. He was the father of Plastic Surgery in America. In 1950 he published a paper on Abbe flaps taken from the lower lip into the upper lip in clefts. He put all of his flaps in funny positions, and they didn't look natural. But they did release the upper lip and they did tighten the lower lip, which is one of the things you want to do. But actually, by principle, if you are thinking of units, even in a unilateral cleft, you ignore the scar and you put the flap in the middle of the lip. You can see what this did. We put an ear graft in her nose, and we brought a mid-line flap from the lower lip into the upper lip and gave her a cupid's bow. And she is doing fine.
An offshoot of the work in clefts was a tether called the Alar cinch where we cinch nostrils. Work on clefts with this technique has been moved to the wide nose. This is a wide, wide broad nose spread out all over. With this technique, we were able to pull the two together, in the same method we use in clefts, and got him that. That has been used a lot of times in a lot of cases.
If we go to the bilateral, I will show you how much more complex that is than the unilateral. The bilateral means it's on both sides and you don't have a cupid's bow and you are short from the tip of the nose to the tip of the lip. There is not enough tissue. The growth of the mesenchyme, coming in from the sides in a cleft, has not pushed through and stretched the middle column of the nose and pushed the cartilage up and pushed the cupid's bow down. All of that has failed. So you have another problem. You have to approach it in a little different way, but we use the same general action. As you can see above, that's two advancement flaps into the center of the prolabium. Here's a child with a bilateral. Here he is with his lip done. You had to make the cupid's bow here. This was made because there isn't one. The other problem was a short columella. Gensoul, a Frenchman, in 1833 described this V-Y flap, in which he realized that they needed more skin in the nose to make the nose more normal.
In Asheville, in the summer of '56, I was at St. Joseph Hospital and I had a case and Barbara was there watching. She used to come in and watch on a lot of the cases to learn about plastic surgery and what I was doing, and she stimulated me that day. I got sort of excited. I was going to do this operation on the left, and I thought that makes three scars, and I don't want that in this kid. So I developed the forked flap, which is in principle: To borrow from Peter to pay Paul. There is the design. That allowed me to make the fulcrum smaller, to get enough for the columella to make a cupid's bow, and, in general, to get a more normal overall effect. That was the result on that little girl that I am telling you about in Asheville. Then I came back and we gradually worked out how to make a cupid's bow with flaps from the sides. Then we would take flaps of the fork and put them up in the floor of the nose, and then later move them in to make the nose and reconstruct it. This is an example of that. We showed you the before picture, and this is his profile.
Then when Latham came, he hooked onto this - you see - and got these projecting premaxillas and all into normal position and then it was so much easier. The platform was ready. And we are through by the age of four. That's what we are doing now. That child went into this, and in this one you see the flap. Then we take the fork and move it up in there and get him a nose and a lip and the tip of the nose is up. This is just one that I happened to have heard from just recently. It's another bilateral cleft and here is her result. She came in for a little more touch-up work, but her mother has sent me a note telling me that she has just been accepted at Harvard.
When the tissues are put together in a cleft like this and they are not right, the tissues are pulled, and tight and the face looks like it hurts. Now you have to do a lot of shifting. The tissue is there; you just have to shift it. Here is a design of the shifting. The middle portion moved into the nose, the lateral lips came around, and we took a mid-line Abbe from the lower lip. You all should know how to do that by now. Here she is when she was finished. This is a fellow that had been done in Canada. They had taken a flap of hairless skin because he had such a bad cleft, which wouldn't grow hair. It was terrible. You couldn't take it out because an Abbe flap from the lower lip…look how small the mouth is, if you took that you would have no mouth. He couldn't open his mouth at all. So, we had to leave what we had and we had to do something about it. That is a good quiz, a good question. What are you going to do? I asked him if he'd like to have a mustache. He said, "yes." So, we took one down from the non-balding area behind the pate and he was able to cover it pretty well.
That is all the cases. Now I want to talk a little about the teaching. It's been such a privilege to be at the University of Miami and have a chance to be chairman. I worked here for forty years, but I was chairman twenty-eight years and we were able to pick our own people. We only fired three, and I am only sorry about two others that we let go through. Out of eighty-five, that is not too bad. The foreigners come and go a little more differently and they are not as carefully selected, but they go back to their countries. At one time in England we had as our graduates a Chief of Plastic Surgery at Oxford University, Cambridge University, Liverpool, Hull, Bristol and Nottingham and the University of Edinburgh. We have reached out. This is the creed we have taught through it all for plastic surgeons wherever and whenever, and that is more or less what we have been talking about all along. Here are the fellowships of all the countries that have come. Portugal and a few others should be added, because this was made a few years ago. Here are some of the areas where we have chiefs at universities, program chairman. There have been about eight books written by our boys, and I tell you we are very proud of them.
Now to go back to whom I owe the most. Of course, Barbara, who through it all, knew it all and helped me with the pitfalls and the barriers and all the different things. She knew more about it and often changed my operation. Told me how to do it right. And John Devine, who at the age of sixty, after thirty years as a board general surgeon, came here and I saw what a great guy he was and so we trained him and at sixty-one or so he started his plastic surgery career. He worked twenty years. He worked under George Irvin, who was Chief of Surgery over at the Veterans. He took an iron hand on that situation, and then any of us that he wanted came over to help when he needed. He had a pretty good unit over there. John's not doing so well now, but we had a happy time with him and we will never forget him. Then of course our three little inspirations, and they are now big inspirations, and some of them with their own little inspirations. Thank you very much for your patience. I forgot two mentions. I meant to mention Charlie Lee who is trained in ENT and is an historian and now in plastic here, and has helped us do a lot of this work. And Bruce Cass, who made one of those charts over there that we all appreciate.
D. Ralph Millard, M.D
December 4, 1997
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