Anatomy and Plastic Surgery

Abstract

Seven articles were written on the relationship and interaction between anatomy and the plastic surgery.

3.1 Stiff Twin Compasses: Anatomy and Plastic Surgery

As stiff twin compasses are two;

Thy soul, the fix’d foot, makes no show

To move, but doth, if th’ other do.—John Donne

Years ago, I visited Guy’s campus of King’s College London to meet Professor Harold Ellis, the author of “Clinical Anatomy.” As I explored the campus, I happened to come across Guy’s chapel, where I saw the tomb of Thomas Guy (1644–1724), who was a British bookseller, speculator, and the de facto founder of Guy’s Hospital.

Among the several tombs in the chapel, a lead-lined stone sarcophagus caught my eye: Astley Paston Cooper (1768–1841). His name reminded me of his famous quote. In his days, without anesthetics, surgeons had to work quickly, precisely, and with indifference to the pain they inflicted. Therefore, he said that “A good surgeon must have an eagle’s eye, a lady’s hand, and a lion’s heart.” However, even in the nineteenth century, a sound knowledge of human anatomy was more important than the above three virtues [1].

Over the centuries, most surgeons, such as Dr. Cooper, were “surgeon-anatomists,” who self-pursued knowledge and understanding of anatomy as the foundation of successful surgical results.

However, recent advances in medical education have ironically led to the separation of anatomy and surgery. In some medical schools, including my college, cadaver dissection time has been reduced and replaced with prosections, plastic models, and computer-based multimedia learning [2].

In my department, year 3 students in the 4-year medical program complete clerkships. Some of them still remember the structures of the head and face, but most forget them as soon as they take the corresponding examination in their first year.

As cadaveric training may be best suited for surgical residents, we had weekly cadaver dissection seminars for 5 weeks every year when I was the program director of my department. Residents dissected and exposed structures for days and then demonstrated the structures in front of the surgeons and anatomists of the department.

In workshops of American Society of Maxillofacial Surgeons and Arbeitsgemeinschaft für Osteosynthesefragen craniomaxillofacial division (AOCMF) courses, they use a saw-bone, but participants cannot directly experience the cadaver dissection. If anatomy is included on board certification examinations, especially in the form of an objective structured clinical evaluation, as well as on the written examination, the training staff will prepare their trainees by teaching them the anatomic details of the surgical procedures that they study.

There are many opportunities for anatomists and surgeons to work together to improve educational instruction about anatomical regions known to be difficult, to refine procedural training, and to develop new techniques and procedures.

During surgical procedures, some surgeons are prone to think that they are the first to find a “new structure” that has never been described before. In these occasions, anatomists and histologists play a vital role in helping surgeons, if our forerunners have already defined and named a structure or if vigorous discussions have already been conducted in forums such as “Nomina Anatomica.” Surgeons and anatomists could thereby share a mutually beneficial relationship and greatly enhance each other’s academic productivity.

The next day, I visited the National Portrait Gallery and saw the portrait of John Donne (1572–1631) (Fig. 3.1), the author of the famous poem “A Valediction: Forbidding Mourning.”

If they be two, they are two so

As stiff twin compasses are two;

Thy soul, the fix’d foot, makes no show

To move, but doth, if th’ other do.

And though it in the centre sit,

Yet, when the other far doth roam,

It leans, and hearkens after it,

And grows erect, as that comes home.

Fig. 3.1

A portrait of John Donne as a young man, c. 1595, reproduced with permission from the National Portrait Gallery, London

I believe that anatomy and surgery are 2 feet of stiff twin compasses, just as John Donne wrote. Anatomy is the center foot, which is fixed but leans toward the other moving foot. Surgery, in contrast, is the moving foot, which comes home.

3.2 An Oculist and a Musician in Leipzig

I was present at a feast of St. Lucia, so famous for curing defects of sight (

Fig. 3.2

Saint Lucy (Domenico Beccafurni, 1521, Pinacoteca Nazionale, Siena)

Fig. 3.2).—John Taylor

I recently visited Leipzig to collaborate with a physicist who is involved in a European Research Council project. In that city, I visited the St. Thomas Church (Thomaskirche), where Johann Sebastian Bach worked as a music director from 1723 until his death in 1750.

My colleague said that Bach had cataracts in his late years and underwent cataract surgery performed by an oculist named John Taylor (1703–1772). Because of two surgical errors of couching (a needle was poked into the eye and the cataract-clouded lens was pushed into the rear of the eye, out of the field of vision), Bach developed a painful postoperative infection and was treated with laxatives and the favorite cure of his day: bleeding. He was blind when he dictated his final work and died a few months later.

It is not widely known that Taylor performed many aesthetic procedures, including repairs of blepharoptosis, which became common a century later in the age of Dieffenbach. He also removed a cicatrix from the lower eyelid of a burn patient [3]. Since there were no local anesthetics at the time, the pain was excruciating, and the patient shouted repeatedly “You hurt me!” Taylor replied, “Remember, Lady, Beauty! [4, 5].” When he finished, the women’s friends were astonished and the postoperative result looked like a miracle. Despite his skill, Taylor was considered a “quack” by the Edinburgh Royal College of Physicians, which excoriated him in print [3].

Thus, when do we suspect quackery, and what is the difference between orthodox plastic surgery and quackery?

When Taylor arrived into town, he was heralded by placards and handbills, and his coach was decorated with paintings of eyeballs and the motto: Qui dat videre dat vivere (He who gives sight, gives life) [6]. In modern days, on the outside of buses and inside the subway, we can easily find advertisements for plastic surgery clinics and their preoperative and postoperative pictures.

According to Coats, Taylor’s knowledge was good; he was a shrewd observer and not without original ideas, but his actual practice was deeply tainted with the “dishonest arts” of the quack. The characteristics of charlatans are bombast, effrontery, dishonesty, and ignorance. Taylor showed all these elements except ignorance, and this is his chief condemnation [7, 8]. Thus, Coats concluded that that a knowledgeable but dishonest doctor should be condemned.

The difference between medicine and quackery is that medicine should be based on high-quality evidence, and surgery on anatomical basis, not on opinion [9]. We surgeons need to be much more honest about what we do not know.

3.3 A Plastic Surgeon Striving for Anatomical Knowledge

Wer immer strebend sich bemüht, Den können wir erlösen (He who ever strives, he can be redeemed).—Goethe (1749–1832)

Recently, I visited Leipzig to collaborate with a physicist who works at the Max Planck Institute. While in Leipzig, I visited Leipzig University, the home of many renowned researchers, such as August Möbius (famous for the Möbius strip) and Werner Heisenberg (known as his uncertainty principle). There, I saw the statue of Goethe (Goethedenkmal), which reminded me of the name of a pub (Auerbachs Keller) located in Leipzig.

My accompanying Korean researcher led me to the tavern and said that Goethe (1749–1832) was a regular at Auerbachs Keller as a university student from 1765 to 1768, so he later made the tavern a household name in Faust.

In Faust, Mephistopheles leads Dr. Faust to this pub as the first destination on their travels to show him the pleasures of the tavern (Fig. 3.3). The first edition of Faust contains a figure illustrating the tavern, where four men were drinking. Goethe describes the tavern here as the “devil’s ride on a wine barrel:” “Doctor Faustus at this tide, Out of Auerbach’s cellar did ride, Upon a wine-cask up sped he, As many a mother’s son did see.”

Fig. 3.3

Dr. Faust and Mephistopheles in Auerbachs Keller

In a classic German legend, Dr. Faust was highly successful but dissatisfied with his life and made a pact with Mephistopheles, exchanging his soul for unlimited knowledge and worldly pleasures. The term “Faustian” implies an ambitious person who surrenders moral integrity to achieve power and success for a delimited term.

Nowadays, many areas of plastic surgery have bloomed, especially aesthetic plastic surgery. On the sides of buses, inside the subway, and on the Internet, we can easily find advertisements for plastic surgery clinics and their pre- and postoperative pictures. Some surgeons make presentations at a conference primarily to have pictures taken for their homepage. Some surgeons write papers just for the sake of being able to advertise that they have written articles. In certain clinics, the surgeon who owns the clinic employs a “ghost surgeon” who operates on patients instead of the surgeon who interviews the patients. I am afraid that some successful surgeons are likely to be “Faustian.”

As a plastic surgeon and an anatomist, the soft tissue anatomy of the face is my lifetime project. I visited Leipzig to meet with a physicist who is working on a high resolution 7-T magnetic resonance imaging system. During my stay at his institute, he took magnetic resonance imaging scans of my face four times with different facial coils and at different resolutions, and he shared the images with me. I hope that this development will be a major milestone in imaging, but we have a long way to go.

In that tavern, with a Korean researcher who is working there, we acknowledged the work of Gotthold Lessing (1729–1781), the poet who first made Faust saved rather than damned. At the end of the work, a celestial voice was to cry: “Don’t gloat. You have not triumphed over Man and Knowledge. God has not given Man the noblest of impulses only to make him eternally miserable.”

As a plastic surgeon striving for anatomical knowledge, I encourage myself with the phrase, “Wer immer strebend sich bemüht, Den können wir erlösen (He who ever strives, he can be redeemed).”

3.4 Corrugator: Muscle of Empathy and Determination

Never give in. Never give in. Never, never, never, never—in nothing, great or small, large or petty—never give in, except to convictions of honour and good sense.—Sir Winston Churchill

According to Gray’s Anatomy, the corrugator supercilii muscle arises from the medial end of the superciliary arch and inserts into the deep surface of the skin, above the middle of the orbital arch. The corrugator draws the eyebrow downward and medially, producing the vertical wrinkles known as glabellar frowns.

These wrinkles are regarded as an expression of suffering and might produce the picture of premature aging even in a young person [10]. Thereafter, many treatments to reduce or abolish the action of corrugator have been developed and are being performed as if this muscle is “the muscle of suffering.”

Then, will we be all happy without glabellar frown wrinkles if we have nonfunctioning corrugator?

We should not forget that the corrugator also contracts to prevent high sun glare, pulling the eyebrows toward the bridge of the nose, making a roof over the area above the middle corner of the eye [11].

de Wied et al. compared the electromyography (EMG) activity of the corrugator and zygomaticus in patients with disruptive behavior disorder (DBD) and normal controls. The corrugator muscle response pattern was less pronounced for patients with DBD than for the normal controls. Since lower empathy scores were obtained for patients with DBD than for normal controls, the authors concluded that facial mimicry responses to angry facial expressions were subnormal in patients with DBD, and this may be sign of a deficient early component in the process of emotional empathy [12]. Varcin et al. measured the EMG activity of the corrugator supercilii and zygomaticus major muscle in patients with schizophrenia and controls with viewed images of happy and angry facial expressions. In contrast to controls, individuals with schizophrenia showed atypical facial mimicry reactions that were not associated with any clinical features of the disorder. The authors concluded that the low EMG of corrugator and zygomaticus major is the evidence for a low-level disruption of empathizing deficits in schizophrenia [13]. Through these papers we can see that the corrugator plays a role in empathic responding and regard it as the “muscle of empathy.”

This April, I met an English dermatologist at a conference and he showed me the picture of Sir Winston Churchill with his deep glabellar frowns (Fig. 3.4), which shows his image of “determination” [14]. I agreed with his opinion because Churchill perpetually demonstrated enthusiasm, determination, and optimism—if not at all times in private, then at least always in public [15].

Fig. 3.4

Sir Winston Churchill (1874–1965)

The corrugator should not be despised as a “muscle of suffering.” It should be respected as a “muscle of empathy and determination.”

3.5 An Anatomist’s Contribution to Blepharoptosis Surgery: 100th Anniversary of the Whitnall Ligament

Most plastic surgeons or ophthalmologists who deal with blepharoptosis are expected to have heard about the Whitnall ligament. In Gray’s Anatomy, 39th Edition [16], Fig. 41.5, which shows sagittal and horizontal sections of orbital fascia, is reproduced from Whitnall [17].

Despite his famous name, his publications or his careers are not widely known to many plastic surgeons. I have carried out a survey about the publications and careers of Dr. Whitnall among Korean plastic surgeons. Most of the respondents knew about the Whitnall ligament; however, their knowledge of Dr. Whitnall himself was rather superficial.

This article is not a bibliography of Dr. Whitnall. It aimed to elucidate who he was, what he wrote, and how he contributed to blepharoptosis surgery.

Anatomy of the Human Orbit and Accessory Organs of Vision was first published in 1922, and its second edition in 1932 (Fig. 3.5) [17]. I first encountered this famous book in 1991 just after my completion of plastic surgery residency. I borrowed the book from the British Council Library in Seoul, South Korea, and cited it in some of my articles, including one published 1998 in the British Journal of Plastic Surgery. According to a Google search, the book has been cited 281 times, which is more frequent than Wolff’s Anatomy of the Eye and Orbit [18], which is cited 211 times.

Fig. 3.5

Anatomy of the Human Orbit and Accessory Organs of Vision by Whitnall in 1932

Although the structure so-called Whitnall ligament is described in his book, it is first described in his article titled, “On a ligament acting as a check to the action of the levator palpebrae superioris muscle [19],” in 1911, exactly 100 years ago.

In this article, he described, “The superficial layer of the fascial sheath of the levator palpebrae superioris is very thin over the posterior half of the muscle, but traced forwards is seen to become gradually thicker, until just before the levator expands to form the palpebral aponeurosis, the overlying sheath of connective tissue becomes condensed to form a ligament which stretches transversely across the muscle and extends laterally to the walls of the orbit on either side, to which it has the following attachments: on the inner side the main connection is with the pulley of the superior oblique muscle, but behind this some fibres can be traced directly to the bone, whilst in front of the pulley a well-marked slip of fascia passes forward to bridge across the supraorbital notch, being inserted into the bone at either side of it. Externally, the ligament is fixed to the capsule of the lacrymal gland, and also directly to the bone. The ligament lies free above the aponeurosis for the most part, but laterally a few strands of tissue connect the two.”

He first described the ligament that stretches transversely across the muscle, which was later renamed as “superior transverse ligament of Whitnall” by other surgeons [20,21,22,23].

In a memoriam in 1950 in the Journal of Anatomy [24], the details of his life was revealed. Samuel Ernest Whitnall was born on 1876, at Eccles in Lancashire, United Kingdom. He obtained his doctorate MD and BCh degrees at Magdalen College, Oxford, in 1905, and he worked there from 1908 to 1919 as a demonstrator of anatomy. In 1919, he was called to the McGill University as professor of anatomy and spent the next 15 years in Canada, where, in 1921, the Anatomy of the Orbit was published. It was in 1935 that Whitnall returned to England to occupy the chair of anatomy position at Bristol University, a post that he held until his retirement in 1941. On February 19, 1950, at the age of 74, he died.

I have tried to find some relics belonging to him, such as books or instruments he used while working at Oxford University, McGill University, and Bristol University but without success.

Recently, I obtained a booklet published in 1933 titled, The Study of Anatomy: Written for the Medical Student [25] by Dr., Whitnall (Fig. 3.6). It was written as a student’s guide-a vade mecum. It was a most attractive and extremely sane piece of writing, and JAMA’s book notice wrote, “The students who read it will be influenced through it to be happier and sounder doctors, wiser friends and better gentlemen [26].” After reading this, I was convinced that he was a good teacher as well as a famous anatomy professor.

Fig. 3.6

The Study of Anatomy: Written for the Medical Student by Whitnall in 1933

The condensation of the levator sheath Dr. Whitnall described is now widely known as the “superior transverse ligament of Whitnall,” which is an unassailable landmark in blepharoptosis surgery. Dr. Whitnall should be remembered as a pioneering anatomist and a fine teacher. He left an indelible mark on clinical anatomy with his masterpiece, Anatomy of the Human Orbit, which is still being cited in many articles.

There is an Oriental saying, “Tigers leave fine hides when they die, and people leave their name on their departure.” Dr. Whitnall has surely left his good name, which will be remembered for generations to come.

3.6 Form Follows Function, Function Follows Form

Whether it be the sweeping eagle in his flight, or the open apple blossom, the toiling work-horse, the blithe swan, the branching oak, the winding stream at its base, the drifting clouds, over all the coursing sun, form ever follows function, and this is the law.—Louis Sullivan

“Form follows function,” a famous maxim coined by architect Louis Sullivan (1856–1924), articulates the principle that the shape of a building or object should directly relate to its intended function or purpose. This principle has been a guiding light of twentieth-century modernist architecture and industrial design.

He wrote “Where function does not change, form does not change” and stated that “It is the pervading law of all things organic and inorganic, of all things physical and metaphysical, of all things human and all things superhuman, of all true manifestations of the head, of the heart, of the soul, that the life is recognizable in its expression, that form ever follows function. This is the law [27].”

This credo has been applied in different fields, including product design, software engineering, and automobile design.

In biology, this principle means that the form and shape of a body structure is related to the function of that structure. The systems of the body do not have structures that are planned in advance; instead, over the course of evolution, structures change to allow novel ways of functioning, and organisms with those structural innovations survive to produce the next generation [28].

As a surgical anatomist, I believe that human structures have been structured according to the functions their associated with use, and that form is altered by the required function (form follows function), as in Lamarckian evolution.

As a plastic surgeon, I think otherwise. I know that changing the form can improve the function (function follows form). For example, blepharoplasty improves peripheral vision in aging eyelids, jaw surgery results in precise occlusion in malocclusion patients, and palatoplasty is necessary for speech in children with cleft palate.

Recently, I enjoyed the movie “Ando Tadao,” a documentary about a self-taught Japanese architect characterized by “critical regionalism.” Ando Tadao (1941–) said: “Dwelling in a house is not only a functional issue, but also a spiritual one. In a spiritual place, people find peace in their heart (kokoro), as in their homeland.”

In the Church of the Light in Ibaraki, Osaka, light enters from behind the altar from a cross cut in the concrete wall that extends vertically from the floor to ceiling and horizontally from wall to wall, aligning perfectly with the joints in the concrete (Fig. 3.7). In the Water Temple in Honpukuji, a statue of the Buddha is hidden behind two concrete walls, and only the roof, a pond, can be seen. However, it was built such that a ray of light hits the statue at the hour of sunset. Ando’s buildings are certainly exceptional to the credo “form follows function,” as their form is designed to induce a new function.

Fig. 3.7

Church of the Light in Ibaraki, Osaka

Plastic surgeons are continuing to develop new methods to improve their techniques for changing the form of the human body. The human body, like a dwelling place, is not only a functional issue but also a spiritual one. We should consider patients’ spirit, as well as their body, and remember that function follows form.

3.7 Surgeon-Friendly Anatomy

Doctors without anatomy are similar to moles: they work in the dark and their daily tasks are mole hills [29].—Friedrich Tiedemann (1781–1861)

Ever since submitting my first anatomy paper to the Journal of Craniofacial Surgery just over 20 years ago [30], I have been confident that my anatomy papers would be useful to my plastic surgeon colleagues. The reason for my pride was because I started every study to fulfill the curiosity arisen from my own surgical experiences. In almost every paper, I wrote the following phrase: “The aim of this study is to elucidate the precise anatomical detail of (a structure) relating to (an operation).”

However, my belief of “user-friendly papers” may not have been so correct. Recently, I have received a letter from an American board-certified plastic surgeon. He sent me a picture of his sub-superficial muscular aponeurotic system (SMAS) dissection and asked me the name of a strand cephalad to the zygomatic major muscle as it goes under the orbicularis oculi muscle. He also asked me if it is a sensory nerve. As I could not identify the nerve within the photograph, I sent him a paper from my previous work, which I thought would answer his question. Cheek and lower eyelid en bloc from the bone was harvested and dissected from the periosteum to find the branches of facial nerve in the study [31]. Several days later, there was a discussion regarding the anatomical structure with him, face to face. He said that he could not find the answer to his question as the paper was “not user friendly.” Since he found the branch in sub-SMAS dissection, the topographical anatomy, though clearly showing the most distal branches deep to the muscles, could not quench his thirst for the surgical anatomy.

After the discussion, I searched for the “surgeon-friendly anatomy” and answered myself that surgeon-friendly anatomy should have several surgical perspectives.

The structures should be localized in topography relating to the anatomic landmarks. A landmark is anything that helps us know where we are. If we’re sailing from Plymouth to New York, the Statue of Liberty will be the landmark that lets us know we’re in the right port. Similarly, an anatomic landmark is a morphologic feature of the anatomy that is readily recognizable and may be used as a reference point for other body features [32]. The structures should be demonstrated in layer-by-layer dissections along the surgical plane as “the field real.” Additionally, the depth of the structure should be displayed using histology or tomography.

Since facial appearance, including several intraoral and extraoral parameters, varies in different ethnic origins [33,34,35], transracial anatomy should also be in consideration to enhance the safety of the patients in different races.

Finally, I hope my further anatomy papers move “from strength to strength” (a medieval homiletic phrase) with the constructive feedback given from the plastic surgeon colleagues.