CHAPTER I HISTORICAL THE origin of plastic surgery is of the greatest antiquity. From time immemorial rhinoplasty has been performed in India for the relief of the dis- figurement caused by punitive mutilation of the nose. Two methods appear to have been employed, though the forehead-flap is the only one the use of which has survived in India to this day. A method embodying the use of cheek-flaps is described in the Ayurveda, the sacred medical record of the Hindoos, but it has had to yield to the forehead- flap method a striking parallel to what has occurred in Europe in the last few centuries. The French (or German) cheek-flap method has been relegated to the lumber-room of surgery, and a development of the Indian method, which includes the important improvements evolved by Keegan and Smith, has pride of place Jx^djiy. In perusing the literature of this subject, one is struck chiefly with the lack of appreciation of the need for a lining membrane for all mucous-lined cavities. Not until Keegan's time was it given any prominence, and perhaps even he did not appraise it at its true value. And so it is that the various classical methods take their name from the covering flap employed. In actual fact, except that forehead skin most closely resembles nose skin, the origin of the covering is the least important part. The Italian method, which originated apparently in Sicily about 1415 and was developed by Tagliacozzi in Italy forty years later, consists in the transference of skin for a nose-covering from the patient's own arm, in two stages, the patient being immured in a fixation apparatus while the flap takes. This method was feasible in those stern times, but the more than irksome fixation is not tolerated by the modern patient, and it has been discarded. The principle on which it is based, however, is of wide application, and a modification of it, the author's tube-pedicle method, is in routine use for some of our operations. As in rhinoplasty, so in the rest of present-day plastic work, the principles laid down by the fathers of surgery are found still to be of general application. There is hardly an operation hardly a single flap in use to-day that has not been suggested a hundred years ago. But our work is original in that all3
