Disfigured WWI Vets Were the First Plastic Surgery Patients

This article originally appeared on Tonic Netherlands.

The origin story of plastic surgery is a particularly bloody one—odds are, the very first procedures ever done didn’t come from a place of vanity, but rather one of necessity. The question was more about which patient was desperate enough—and what doctor was fearless enough—to try these risky operations for the first time.

Many of the techniques and practical objects we use today were born during emergency situations in wartime: the radio, the wrist watch, stainless steel, the zipper, daylight savings time, spray bottles, ballpoint pens, and feminine hygiene pads, just to name a few. Similarly, plastic surgery wouldn't be what it is today if a bloodbath that took place 100 years ago hadn't left hundreds of thousands of men disfigured.

The years leading up to WWI marked a time of major technological advancement. Electricity, mass production, steel, and chemicals created weapons that were deadlier than ever before. Soldiers on all sides of the conflict were met with the force of machine guns, flame throwers, tanks, poisoned gas, and airplanes for four years straight. The trenches they dug often protected their bodies, but their heads were all the more vulnerable.

Many of these disfigured WWI veterans became socially isolated as a result, too embarrassed by their own appearance to appear in public. Often, they didn't even want to show themselves to their own family members. A regular job or social life was impossible. A British veteran who was hit by grenade shrapnel during the Battle of Ypres was afraid to eat in public because his wounded face made such unappetizing sounds while he chewed and swallowed.

To hide their disfigurations, many veterans were fitted with a mask or a facial prosthetic. Today, these prosthetics are usually made of silicone, aluminum, or plastic, but at the time they were made from copper and other type of metals. A missing nose, lip, cheek, jaw, or eye socket was replaced by a partial mask, often kept in place by a pair of glasses. It was an ugly and impractical short-term solution—one that may not have improved if a physician named Harold Gillies hadn’t taken an interest in the problem.

Gillies was an adventurous ear, nose, and throat doctor from New Zealand who had come to England during the war. He felt for the wounded veterans and erected a special section for facial surgery at the Cambridge Military Hospital. There were no mirrors on the walls and the benches in the park by the hospital were painted blue to indicate that they were meant specifically for patients, but also to warn passersby they might see some gruesome-looking people.

Gillies quickly recognized that the damage caused by social isolation was often greater than the functional damage done to the body. His primary goal wasn't to restore the physical functionality of the patient's face, but to reconstruct it aesthetically. Gillies thoroughly researched the blood flow and nerves in the human face. Amongst other places, he took inspiration from India, where noses were regularly chopped off as a form of punishment. From there, he borrowed the idea for the first nasal reconstruction: a technique that uses a piece of cartilage from the ribcage and places it underneath the skin on the forehead.

Once the wound healed, the cartilage was cut off and folded down to act as a new nose. At first, the piece of skin was still attached to the forehead to keep blood flow intact, until the new nose has become a part of the face. This "pedicle flap" is still used in different variations when performing skin transplants, especially when performing reconstructive surgery on burns, serious injuries, and amputations.

The so-called "pedicle tube" is another technique Gillies pioneered. The skin is partially cut off and then stitched together, forming a sort of tube made of flesh. The blood flow remains and the risk of infection is small. One part of the tube is still attached while the other end is stitched onto the surface the skin will ultimately end up on. Once grown together, the place where it was originally attached is cut loose, and the skin is put in place. This technique is still used by plastic surgeons today.

Gillies and his colleagues operated more than 11,000 times on upwards of 5,000 patients. These long and often experimental treatments could take years; a period that was painful and uncomfortable for the patient. Many treatments were ultimately not successful.

Experimenting on the disfigured faces of WWI veterans happened elsewhere, too. In the Netherlands, for instance, eccentric doctor called Johannes Esser, who is considered to be the founding father of reconstructive and plastic surgery in the Netherlands, spent years working in camps where thousands of disfigured young men were sent to live after the war. He developed theories about blood flow, nerves, and the anatomy of the face and created techniques that are used to this day. The "island flap," for instance, is a technique meant to transplant a piece of skin over a short distance on the body. The nerves and blood vessels are moved so that underneath the skin the body is still connected to the transplanted piece. This technique is still used for facial reconstruction of the upper lip, nose, ears and around the eyes.

Esser was so galvanized by his work that he made plans to create a Surgical Free State: an independent small state—ideally located on an island—that would feature a plastic surgery hospital and clinic and would even have its own currency and stamps. He had appointed himself as primary physician and CEO, and for 10 years, he traveled around the globe to gather support for his plan. He wasn’t altogether unsuccessful: many famous heads of state, doctors, and even several Nobel Prize winners—including Einstein—got behind his idea. Unfortunately, most of Esser’s money evaporated in 1940 due to a bad investment in the US stock market. After that, he spent a few years traveling through the US in a van while attempting to make living as a public speaker. He briefly worked on his memoirs while living in squat housing in Chicago and died there in 1946.

The end of World War II found more soldiers returning home with wounded faces. This time, more of them had suffered from severe burns. Improved anesthesia and antibiotics were instrumental in helping them make it through surgeries, whereas in the past they likely wouldn't have survived them.

At the start of WWII, Gillies' cousin Archibald McIndoe started the so-called Guinea Pig Club. It was a social club that doubled as a support network for patients, doctors, and nurses at Queen Victoria Hospital for Plastic Surgery in England. Just like his cousin, McIndoe saw the importance of social reintegration for disfigured veterans, many of whom were pilots who had participated in the Battle of Britain in 1940. The rather dark name of the club, which existed until 2007, refers to the experimental nature of the treatments, techniques, and surgical tools McIndoe used. The procedures still took a long time, hurt a lot, and the chances of success weren't terribly high.

In the 1960s and 1970s, interest in cosmetic surgery grew: Modern materials and techniques like the use of silicone paved way for the first breast enlargement and other aesthetic procedures. This new kind of surgery became more well known in the 1980s, as globalization, mass media, and economic growth created access that hadn't been possible before. Instead of trauma patients, more and more people soon found their way to the plastic surgeon's office. It became a new specialty—one that transformed beauty ideals from mere dreams into things that could actually be attained.

At first glance, the primitive and often gruesome methods that were used on veterans don’t seem to have much in common with the smooth perfection sought by the customers of a modern plastic surgeon. Still, today’s consumers have reaped the benefits of techniques like Gillies’ tube, Esser’s "island flap," and the intricate work McIndoe did to restore the burned-off eyelids of his patients. Their anatomical research—along with the knowledge they gained about blood flow and facial nerves—put plastic surgery on the fast track to reaching a more mainstream audience.

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