Plastic Surgeon’s View of Artistic Works

Abstract

Nine episodes about works of art were collected from the perspective of a plastic surgeon.

2.1 Aretê of Athletes, Self-discipline of Plastic Surgeons

Areté is a word that means excellence in character and life. It is the accumulation of virtue in one’s life.”—Tobin Wilson (Author of Areté Again)

The 2021 Olympic Games were held successfully in Tokyo despite the COVID-19 pandemic. The players competed to their utmost ability in the state of aretê.

Aretê (ἀρετή) is a term associated with the Greek goddess of virtue and knowledge that denotes excellence in anything or of any kind (Fig. 2.1). This term may also mean “moral virtue”. In Greek, aretê was ultimately bound up with the notion of the fulfillment of purpose or function: the act of living up to one’s full potential. In the Homeric poems, aretê is frequently associated with bravery, but more often with effectiveness. A person with aretê is of the highest effectiveness; he or she uses all available faculties—strength, bravery, and wit—to achieve real results. In the Homeric world, then, aretê involves all of the abilities and potentialities available to humans.

Fig. 2.1

Ancient Greek Athletics: Aretê

Olympic athletes have aretê. Since winning the ancient Olympic Games was impossible without the patience and courage to undergo hard training, endure the possibility of defeat and disgrace, and even risk one’s life, winning proved the aretê of a human being. Aretê is that state of self-denial and of personal agony, anguish, and perseverance that was considered to be pleasing to the gods and necessary for accomplishing a superior task. At the coronation ceremony of the winners gathered in front of the Temple of Zeus, the names of the victors, their fathers, and the city were called out loudly. Honor belonged to the individual, to the family, and to the city-state. The Olympics were the best stage for an individual to dedicate themselves to the city-state. Citizens praised the winner’s aretê with congratulatory poems, songs, and sculptures.

As athletes pursue aretê, what should excellent plastic surgeons learn from this concept?

The biggest threat that hinders one from being an excellent plastic surgeon is the failure to continue to practice. Actual practice with the goal of self-improvement does not simply constitute repeated performance. Progress is not inevitable. Practice involves critical self-analysis of procedures with the goal of performing them perfectly. Therefore, to be excellent plastic surgeons, we also should have aretê, the self-discipline of practice [1].

Self-discipline includes the anatomical basis of treatment and the principles of perioperative care, including fluid and electrolyte balance. The ability to choose when to operate and when not to operate is essential, as well as surgical skills. An attitude of honesty and empathy for patients constitutes the moral virtue of a good plastic surgeon [2].

When I come out of the operating theater, I ask myself whether I just carried out the operation exactly as planned. Although I precisely design the procedures and I usually come fairly close, I have never been able to operate in exactly the same way that I conceive of it in my mind [3]. I have empty note papers on which I write or draw to prepare for operations that I expect will involve complicated procedures. Upon arrival to my office, I recall the procedure and fill an empty page with the procedural steps I performed and my regrets regarding the operation. When these operative notes are collected, they can be the basis of case reports, idea and innovation reports, case series, or even original articles [4].

The winners of the Olympic Games will die 1 day. However, those memories of aretê are perpetuated from generation to generation and became the soul of the polis. Even an excellent plastic surgeon will retire someday. However, the papers published based on the “self-discipline of practice” will serve as a beacon for junior plastic surgeons who will take their place.

2.2 Enigmatic Smiles for Plastic Surgeons

2.2.1 Introduction

Years ago, I visited the Louvre in Paris, where I enjoyed the paintings from the Renaissance period. In the room dedicated to Renaissance paintings, I had the opportunity to see the Virgin of the Rocks and the Mona Lisa. Several people were looking at the Virgin of the Rocks, but there was a very large crowd in front of the Mona Lisa.

Because the Virgin of the Rocks contains content related to religious doctrines (St. John the Baptist and the young Jesus), which is not the case for the Mona Lisa, the former painting was more famous than the latter during Leonardo’s lifetime (1452–1519). In contrast, the enigmatic smile of Mona Lisa was revaluated as time went by, with growing appreciation.

On my way home, I thought about the eternal charm of mysterious smiles and resolved to search for historical examples of enigmatic or mysterious smiles.

The aim of this paper is to review famous examples of mysterious or enigmatic smiles in art history that might be interesting for plastic surgeons.

2.2.2 What Is a Smile and Which Muscles Are Responsible for Smiling?

In Webster’s Dictionary, a smile is defined as “a change of facial expression involving a brightening of the eyes, an upward curving of the corners of the mouth with no sound and less muscular distortion of the features than in a laugh that may express amusement, pleasure, tender affection, approval, restrained mirth, irony, derision or any of various other emotions.”

Rubin wrote that the nasolabial fold is the keystone of the smiling mechanism [5]. He stated that a smile is formed in stages: in the first stage, the levator muscles contract and raise the upper lip to the nasolabial fold, and in the second stage, the levator labii superioris, zygomaticus major, and buccinator muscles raise the lips even more superiorly. He also classified smiles into three categories depending upon the direction of the elevation and depression of the lips and the dominant muscles involved. In commissure smiles, the zygomaticus major muscles pull the upper lip like a Cupid’s bow (as in the smile depicted in the Mona Lisa). In canine smiles, the upper lip is elevated uniformly like a diamond, without the corners of the mouth turning upward. In full denture smiles, the lower lip moves inferiorly at the same time as the upper lip moves superiorly.

2.2.3 Famous Enigmatic or Mysterious Smiles in the Arts

Blessing and well-being in smiles from the archaic period (600–480 B.C.) of Ancient Greece

The most famous examples of the archaic smile are the Kroisos Kouros (a grave marker for a fallen young warrior named Kroisos) and the Peplos Kore (a statue of a girl that was originally colorfully painted) (Fig. 2.2).

Fig. 2.2

Peplos Kore (a statue of a girl, 530 BC)

It has been theorized that artists felt that the archaic smile represented the blessing of the gods for the actions of the figures portrayed. It is also thought that this smile reflected a state of ideal health and well-being.

Warmth and softness in the smile of the Buddha’s face

This smile is exemplified by the Rock-Carved Triad Buddha in Seosan (from the Baekje Kingdom period in Korea; late sixth to early seventh century) (Fig. 2.3).

Fig. 2.3

Rock-Carved Triad Buddha in Seosan (from the Baekje Kingdom period in Korea; late sixth to early seventh century)

Baekje figures express a unique smile that has been described as both enigmatic and subtle. The smile has been also been characterized in many different ways, from “genuinely glowing” to “thin and mild” to “unfathomable and benevolent.” Baekje sculpture exhibited distinct characteristics of warmth and softness and used relaxed poses conveying friendliness and an air of pleasantness that is rarely found in other traditions of Buddhist sculpture.

Serene concentration in the Bodhisattva’s smile

A gilt-bronze Bodhisattva, in a pensive position (sixth century, 83rd National Treasure of Korea), has a face with a hint of a smile that exhibits a sense of serene concentration and gives the viewer the impression of an aura of deep thought (Fig. 2.4).

Fig. 2.4

A gilt-bronze Bodhisattva in a pensive position (sixth century, 83rd National Treasure of Korea)

Hints of happiness and sadness in Gabriel’s smile

Reims Cathedral (also known as Notre Dame de Reims) has four statues forming a composition of Annunciation and Visitation, with two statues each. In Annunciation, the angel Gabriel is sent by God to visit the Virgin Mary to give her the news that she will give birth to the Savior. Gabriel’s gaze is focused on Mary with a hint of happiness but also sadness (Fig. 2.5). He understands her excitement but also realizes the fate of her unborn son. The Virgin Mary gives Gabriel a slight smile from her youthful face as she receives the news of her child.

Fig. 2.5

Statue of angel Gabriel (Notre Dame de Reims Cathedral, 1236–1245)

Happiness or a non-genuine smile: Mona Lisa’s mysterious smile

The painting is thought to be a portrait of the Italian noblewoman Lisa Gherardini, the wife of Francesco del Giocondo, and was painted between 1503 and 1506. Over the years, there have been many debates about the valence of the emotion expressed on her face, but most interpretations agree that the expression depicted in Mona Lisa is happiness (Fig. 2.6).

Fig. 2.6

Mona Lisa (Louvre Museum, 1503–1506)

In a recent paper, a neurobiologist wrote that happiness is expressed only on the left side and that her asymmetric smile is a non-genuine smile, which is also thought to occur when an individual lies [6].

2.2.4 Discussion

Smiles make art history beautiful.

In the archaic period of Greece, smiles represented blessing and well-being. In the sixth century, Buddha’s smile conveyed warmth, softness, or serene concentration. Gabriel’s smile provided a hint of happiness in response to the Virgin Mary’s excitement as well as sadness regarding the fate of her unborn son, who was destined for crucifixion. Mona Lisa’s mysterious smile is generally interpreted as showing happiness but has also been interpreted as a non-genuine smile.

The components of the smile should be considered not as rigid boundaries but as artistic guidelines to help the plastic surgeon or orthodontist. It is important for plastic surgeons and orthodontists to make every effort to develop a harmonious balance that will produce the most attractive smile possible for each patient being treated [7].

In our modern competitive society, a charming smile can be a key to open doors and to knock down barriers to success. From the surgeon’s point of view, however, there is no universal “ideal” smile.

The most important esthetic goal for surgeons is to obtain a balanced—or preferably, enigmatic—smile, as represented in artistic masterpieces from across the ages.

2.3 Robbing Peter to Pay Paul

Your slogan should be: the simplest possible repair with minimum sacrifice of material.—Thomas Pomfret Kilner (1890–1964)

Last year, I visited the Hunterian Museum in London and saw Dr. Kilner’s relics. Among them, I read the draft for a course of lectures in plastic surgery, arranged by the Postgraduate Education Committee of the Royal College of Surgeons (cleft lip and palate repair, February 23, 1948). While I was reading his lecture draft written 68 years ago, I felt as if I was listening to his lecture in the lecture room downstairs. He emphasized “Your slogan should be: the simplest possible repair with minimum sacrifice of material.”

During my stay in London, I also visited two famous churches: St. Paul’s Cathedral and Westminster Abbey. Christopher Wren, the architect who designed the Royal Observatory at Greenwich, designed St. Paul’s Cathedral, and it is famous because Prince Charles and Princess Diana got married there. The full name of Westminster Abbey is the Collegiate Church of St. Peter at Westminster, and it contains many tombs of famous kings, queens, scientists, and poets. The body of Isaac Newton is placed in this church, as described in The Da Vinci Code written by Dan Brown.

The tour guide said that money was taken from the government’s allotment for Westminster Abbey, or St. Peter at Westminster, to pay for the construction of St. Paul’s after the earlier cathedral on the site was destroyed by a fire in 1666 (Fig. 2.7). She told us that this is the origin of the expression “robbing Peter to pay Paul.” This familiar phrase means to take something from one person or thing to pay a debt to another.

Fig. 2.7

Old St. Paul’s Cathedral in London

On my way home, I remembered the “barter principle” I read in the first edition of Plastic Surgery when I was a trainee.

“In making a scalping flap or median forehead flap for subtotal reconstruction of the nose, forehead tissue is used for this procedure because of the good color and texture match. A major portion of the flap is replaced in its original site after dividing the pedicle, leaving a portion of the flap to form the reconstructed nose. However, a secondary defect remains on the forehead. This defect is repaired by the most suitable skin available to minimize the secondary deformity. Thereafter full-thickness skin from the supraclavicular area gives a suitable color match. The supraclavicular defect can usually be closed primarily. This is a good barter; by contrast, a split-thickness graft placed upon the forehead represents an unsatisfactory repair of the secondary defect.”

Reconstructive ladder and elevator/lift have developed reconstructive plastic surgery. Nowadays, we have free flaps for almost every defect; thereafter, we sometimes overlook simpler means of closing a defect to be inferior to the more sophisticated but complex techniques. However, free flap does not always promise a superior outcome. It is time-consuming, costly, and often involves a number of complementary procedures with considerable donor site morbidity.

In reconstructive plastic surgery, surgeons must remember that good clinical judgment reduces the cost of the barter to a minimum. I do think the slogan “Simplest possible repair with minimum sacrifice of material” is still valid until today. Always remember that “Paul must also be able to pay Peter.”

2.4 Metamorphosis From an Ugly Girl to a Beauty

The desire to have a beautiful appearance has been deeply rooted in human beings in all ages and countries. In this era, many women live with an intense interest in their appearance due to the social importance placed on appearance. Some women even suffer from an obsession for a beautiful face and slim body in order to achieve success in employment or marriages, without the discrimination and disadvantages faced by women perceived to be ugly.

Women are often unable to escape from the social emphasis on beauty and the Cinderella complex due to the influence of the mass media and the sociocultural phenomena of discrimination against women based on their appearance and commercialization of women’s appearance. The causes of these sociocultural phenomena may be complex, but it is difficult to ignore the influence of children’s books and animations of old tales that people encounter in childhood. For many years, the female protagonists in children’s fairy tale books and animations have been mostly beautiful-looking princesses, whereas most of the ugly-looking women were witches, cannibals, or evil stepmothers, who symbolized evil or greed, or their daughters.

Is there really no fairy tale in the world where an ugly woman is the main character? In the catalog of international tale types (ATU) based on the Aarne/Thompson system, one (ATU 711. “The Beautiful and the Ugly Twin”) has an ugly female protagonist [8]. This tale has been handed down in Europe.

Another tale that is not included in the ATU index has been passed down in Jewish communities living in predominantly Islamic countries, such as Morocco, Yemen, Iraq, and Persia: “The Ugly Wise Girl.” In this story. The daughter of a rabbi born with a beast’s face finally undergoes a metamorphosis [9].

The summary of the tale is as follows:

Once upon a time in Constantinople lived a girl with a face that resembled a beast. The girl, the only daughter of a rabbi, had a very ugly face, but she was wiser than anyone. Because of her ugliness, her parents locked her up in the attic of the school so that no one else could see her. She received food through a small hole in the door. A young male student from a distant province came to this city to study at the rabbi’s school. This young man studied in a room next to where the girl was locked up in the attic. When he was in trouble because he was unable to answer the rabbi’s questions, he would find notes with the correct answers written on them. When he realized that the notes were written by the rabbi’s daughter in the attic, he was deeply moved by her wisdom and knowledge and finally made a marriage proposal to her. Her parents initially opposed the idea, but later agreed to their marriage. At the wedding ceremony, the groom couldn’t see the bride’s face, which was covered with a veil. The groom was shocked to see her face on the first night; however, he spent the night with her to keep his marriage vows. When he started on a long journey, she asked for a love token for the child to be born, and a ring and prayer shawl were handed over to the bride. The bride gave birth to a son, but she couldn’t raise him, and her parents raised their grandson instead. The son grew up and went to school, where he was teased by his friends for being a fatherless child. After learning the secret of his birth, the son met his mother, who was still staying in the attic. He realized that his mother endured hard times studying the Torah, and the son learned Torah from his knowledgeable and intelligent mother. One day the son asked his mother about the whereabouts of his father and started a journey to his father, carrying the ring and prayer shawl that his father had left behind. After several months of journeys, he arrived in the country where his father lived and entered the synagogue there. When the rabbi saw the prayer shawl embroidered with his son’s name, he recognized that this boy was his own bloodline. The son persuaded his father to return to live together with them since his mother was prettiest and wisest person in the world. Hearing his son’s words, the rabbi thought that a miracle might have happened, and told him he would return home soon. On the way back to his homeland, the son met an old man, who gave him a mysterious drug. The old man told the son to apply it to his mother’s face. Upon returning home, his mother applied it on the face and became as beautiful as the sun and the moon. She prayed to God with thanks for giving a miracle drug through the hand of Prophet Elijah (Fig. 2.8). When the father returned home, he realized that a miracle had indeed happened. This wise son brought peace and happiness to his parents’ home.

Fig. 2.8

Elijah poured the salt in the water and blessed it. “So the waters were healed unto this day, according to the saying of Elisha which he spake” (2 Kings 2:22)

In this story, the protagonist’s transformation was a rite of passage for women entering a society (male-centered, patriarchal society) after enduring trials and pains. The rabbi’s daughter was not able to complete a sequence of rites of separation, transition, and incorporation at her birth, and her parents did not assimilate her into their family structure. For this “ugly girl,” the marriage ceremony could not function as a rite of incorporation because she was abandoned by her husband on their wedding night and then experienced a transitional period in an enclosed room without integration into society through her husband. After her transformation into a beautiful woman, she was able to complete her rite of passage from separation through transition to incorporation [10]. She overcame her hardships through her wisdom and belief in God. The rabbi’s daughter transformed her appearance, thanks to her son, who obtained a bottle of miraculous water from the Prophet Elijah.

In our era, fortunately, women do not have to rely upon God’s grace and miraculous water from the Prophet. Instead, plastic surgeons express their imagination by modifying the living bodies of patients like poets or writers of tales expresses themselves through their writings or poems [11]. If women have free will to transform themselves, many miraculous plastic surgical procedures can replace Elijah’s water, opening a door to the corresponding rites of passage.

2.5 Designing on Paper and Using a Model

How many things painters see in shadows and in the foreground that we do not see? Oh, think what you would say if you could see it with Salvator Rosa’s eyes.—Baldinucci

When I visited St. Peter’s Basilica in the Vatican, I saw a sign at the front of the Blessed Sacrament Chapel that read: “Only those who wish to pray may enter.” It really was the only quiet place for reflection in the crowded and noisy Basilica. At the front was a beautiful tabernacle designed by Bernini. The 12 apostles and Jesus are perched on top of the cornices of the miniature dome. Two large angels are kneeling on the altar in reverent prayer. In our contemplative mood, gazing at the beautiful spectacle, my wife and I soon became oblivious of the noise of the world.

In the Vatican Museum (Vatican Pinacoteca), I chanced upon a similar angel. The iron armatures of the wings and bundled twigs inside the shoulder exposed by damage. It was the full-sized modello for the kneeling angel of the “Altar of the Blessed Sacrament” (Fig. 2.9).

Fig. 2.9

Full-sized modello for the kneeling angel of the “Altar of the Blessed Sacrament” (Vatican Pinacoteca)

After seeing the terracotta models, I acquired a book, Bernini Sculpting in Clay, and discovered that Bernini had used drawing and terracotta modeling as preparatory studies for his marble statues. He began with a sketchbook or model stand.

On my way home, I thought about the modello of the kneeling angel and the use of occlusal plane casting and the occlusal wafer for jaw surgery.

Whenever I meet a patient, I would draw a face schema. If a scar is visible, I would draw it precisely on the paper medical record. For a Z-plasty or W-plasty, I usually design a schematic representation of the procedure on the paper drawing of the scar and show it to the patient.

This led me to think about the use of three-dimensional (3D) silicon models for breast reduction. Even if we do not make such 3D models, similar models can be purchased. By designing the procedure on the model and practicing with different methods, we can choose the most proper method for a specific patient.

Bernini’s models are appealing because of their vitality and their vivid reflection of the sculptor’s touch. The range of his drawings is remarkable in terms of type and quality; Bernini appreciated the versatility offered by various techniques as he grappled with the diverse problems that he encountered in sculptural commissions [12]. Drawings were indispensable to Bernini’s design process, linking his thoughts to his clay models and to the final sculptures.

Changes made in surgery are irreversible, like those made in marble or bronze statues. Like Bernini, the famous artist of the Baroque period, we plastic surgeons also need drawings or models for our operations, to make “the field real.” Performing numerous imaginary operations prior to real surgery will help plastic surgeons to see their patients with “Salvator Rosa’s eyes.”

2.6 Critical Appraisal in Plastic Surgery: Nullius in Verba

Nullius in verba (Don’t take anyone’s word for it)

At conferences, many new techniques are introduced to many audience members, often including myself. Sometimes a new technique with dramatic postoperative results may be especially intriguing. The presenter says that all the patients were satisfied and that no complications occurred. In such cases, we are prone to incorporate at least a part of the method into our routines, or even to change our previous operative method. Of course, the famous surgeon, giving the presentation, has already published his methods in a journal article or a book chapter. Some surgeons develop new surgical nomenclature or propose names for a purportedly new anatomical structure because they think that they were the first to innovate the technique or to find the anatomical structure.

Several years later, a modified technique can be introduced by the same surgeon. At this time, the presenter insists that the new modified method obtained better results. He publishes again, this time with modified methods. Usually, he does not mention why he modified the previous method or express regret for the shortcomings of the previous method. He may introduce a new name for a structure similar to one that he previously named.

Since the famous surgeon says that this new method is better or even best, we are put in the position of having to follow this “virtuoso,” without knowing whether he will change the method once more. We have to use the new terminology as an indicator of being up to date. If we do not use the new term for a method or anatomical structure, we seem out of date and lose the ability to communicate each other.

With the ever-increasing quantity of medical literature, it is impossible for plastic surgeons to read every article, even in their subspecialties. Thus, the critical appraisal of scientific papers is an important skill for plastic surgeons to master. We must start from a position of skepticism because it is the true starting point of science [13].

It is difficult to distinguish papers written just to meet publication requirements from true gems, and we should have our eyes wide open to distinguish trustworthy papers from theses published for their own sake.

If all the patients are satisfied and no complications occurred, the follow-up period should be checked. If new surgical nomenclature or a name for a purportedly new anatomical structure appears in a paper, we must review previous techniques or go back to the anatomy textbook we used in medical school. Papers that do not cite previous papers on similar topics and insist on their originality should be disregarded. If a paper provokes a letter to the editor and the authors do not respond to this letter, it can be concluded that the authors are attempting to avoid criticism [14, 15].

We should not be “conclusion-of-the-abstract readers.” In a systematic review containing a meta-analysis, the data are contained in the few articles that are included in the meta-analysis. Such “evidence-based medicine” is intrinsically dependent on both the direction of the available research and the selection criteria used [15]. Thereafter, when reading a review article, we should consult the guidelines presented in PRISMA (Preferred Statement for Meta-Analytical Studies and Systematic Reviews: http://www.prisma-statement.org) or CONSORT (Consolidated Standard for Reporting Trial 2010 for Randomised Trials: http://www.consort-statement.org).

Nullius in verba (don’t take anyone’s word for it) was the motto adopted by the Royal Society of London for Improving Natural Knowledge in 1660 (Fig. 2.10). I strongly suggest that this motto should also be applied in the field of plastic surgery.

Fig. 2.10

Coat of arms of the Royal Society with the motto Nullius in verba along the bottom

2.7 Clip an Angel’s Wings, Make Man’s Wings

When I visited Guy’s Hospital, London, for my youngest son’s medical school commencement, I happened to see the statue of John Keats (1795–1821) (Fig. 2.11). Despite an early interest in literature, Keats was apprenticed to an apothecary and continued his medical training as a surgeon’s assistant at Guy’s Hospital, obtaining the Licentiate of Apothecaries in 1816. However, he never practiced medicine.

Fig. 2.11

The Keats statue at King’s College London, Guy’s Campus

In his poem, “Lamia,” I noticed some interesting verses: “Philosophy will clip an Angel’s wings.”

There was an awful rainbow once in heaven:

We know her woof, her texture; she is given

In the dull catalogue of common things.

Philosophy will clip an Angel’s wings,

Conquer all mysteries by rule and line,

Empty the haunted air, and gnomed mine—

Unweave a rainbow, as it erewhile made

The tender-person’d Lamia melt into a shade

According to scholars, Keats [16] claims in “Lamia” that scientific knowledge ruins our sense of beauty. It is thought that sole emphasis on science might stifle the creativity. However, his scientific knowledge surely helped him to create poetry of great beauty, even though he decided to pursue poetry rather than a career in medicine. His medical experience also influenced to some degree his ideas and even his choice of words [17].

Upon arriving home, I thought deeply about whether scientific knowledge spoils plastic surgeons’ aesthetic sense and was reminded of a book I have had since my training years: The Artistry of Reconstructive Surgery: Selected Classic Case Studies [18]. In the epilogue of this book, the two surgeons posed the question of “Can man have wings?” as a methodological inquiry. Dr. Brent stated that it would be possible through a “thoracobrachial pterygoplasty (making a wing between arm and trunk using tissue expander) powered by split latissimus dorsi muscle transposition flap and bone grafts.” In contrast, Dr. Krizek proposed creating muscle-powered wings (tissue expanders and uroepithelial rib grafts made flexible by incorporating interphalangeal joints) and conehead buoyancy.

Although these methods are almost impossible in real-world circumstances, these reflections show the potential growth and evolution that lie in the flexible and creative nature of man’s imagination [11]. Commixing the science and creativity lead the plastic surgeons onto innovation.

After reading “Lamia” and the epilogue of The Artistry of Reconstructive Surgery, I began to think that scientists and poets are more alike than I thought before.

Just as the medical knowledge of the doctor Keats helped the poet Keats who sang of physical pain and pleasure, our literary sense as surgeons will help our creativity in developing new innovation of techniques through imagination.

2.8 “Brighter Hours Will Come:” The Signet Ring of Florence Nightingale

We hope for the hours that are brighter to come.—Elizabeth Piddocke Roberts

A lady with a lamp I see.—Henry Longfellow

A Gallup poll asked what jobs people considered trustworthy, and the medical doctor was ranked third among the most trusted professions, following nurses and pharmacists. On the contrary, health maintenance organization managers ranked fifth least trusted position [19]. In South Korea, however, assembly passed a bill recently, which allows victims of medical malpractice to begin legal processes without the consent of hospitals and doctors. This bill represents distrust of the patients and relatives to the medical doctors [20].

It is well-known that Florence Nightingale (1820–1910) became a persona of “The Lady with the Lamp,” making rounds on wounded soldiers at night during the Crimean War (1853–1856). This powerful and recognizable image first came from Illustrated London News (1855). Henry Longfellow (1807–1880)’s poem “Santa Filomena” written in 1857 (“Lo! in that house of misery, A lady with a lamp I see”) fixed forever Florence’s image as the lady with the lamp. This image was enhanced by many paintings.

Many of her relics, including her seal press marked with her initials “FN,” are displayed in the Florence Nightingale Museum, located near St. Thomas Hospital where she first established a modern nursing school. However, her signet ring has not been described yet.

During my 3 months stay in London, I happen to see Nightingale’s seal at Henry Wellcome’s Legacy in the Science Museum London (Object number A134207), which she used to impress wax seals on her letters until her death (1910). The figure and the phrase on the signet ring help provide some insight, thus worth describing in detail.

The ring bears an image of a nurse’s lamp and the phrase “Brighter Hours Will Come” (Fig. 2.12). This phrase was likely derived from the poem title “Brighter Hours Will Come” in the book “Miscellaneous Poems (1845)” written by Elizabeth Piddocke Roberts [21].

Fig. 2.12

Image of a nurse’s lamp and the phrase “Brighter Hours Will Come” in the signet ring of Florence Nightingale

When the winter wind howls o’er the desolate plain,

Or agitates madly the billowy main,

With a rush, and a hollow-toned, whistling blast,

As it moans round the sales, or the tall stately mast,

Oh, where is the mariner, exiled from home,

But sighs for the hours that are brighter to come?

And ‘this thus with the soul, as it struggles with woe,

While o’er us its billows unceasingly flow;

Through the wildest of sorrow, the bitterest grief,

‘Tis in thoughts of the future the mind seeks relief.

Though from happiness now, saddened outcast we roam,

We hope for the hours that are brighter to come.

As King Solomon had carved on his signet ring the phrase “This too will pass away”—which would always be true in good times or bad—the phase “Brighter hours will come” is thought to be Nightingale’s favorite words that gave her hope in difficult times and humility in good times. Then, what was the “brighter hours” for Florence Nightingale? Was it professionalizing nursing roles, or social reforms of improving healthcare? Or was it simply spring the poet was longing for in winter?

As I came out of the museum, I thought about the image of medical doctors depicted in the eyes of the people in these days.

I miss the poets like Henry Longfellow or artists like Sir Luke Fields (1843–1927), who would express the good image of plastic surgeons of this era.

2.9 How to Hold an Osteotome? Michelangelo Grip

Lorenzo laughed and said, ‘But don’t you know old people never have all their teeth; there are always some missing.’ As soon as Lorenzo had gone away, Michelangelo broke off one of the faun’s teeth and dug into the gum so that it looked as if the tooth had fallen out.—Christopher Hibbert

We plastic surgeons, especially craniofacial surgeons, routinely use surgical instruments. It is generally thought that there are no specific rules for how surgeons should hold instruments with their hands. Most surgeons in training learn how to use instruments by observing their teachers. After completion of training, when we have the chance to see other surgeons operate, especially famous surgeons, we carefully observe their hands-on skills and the maneuvers that they use to handle their instruments. If they are sufficiently skillful and their technique seems even better than ours, we can mimic their technique and abandon the technique that we previously used. However, I believe that this rarely occurs because we are stuck in a rut, following the law of inertia.

The osteotome is a surgical instrument that is frequently used in rhinoplasty as well as harvesting bones. When I use an osteotome, I support its bottom with my left thumb and hold it with the remaining four fingers (Fig. 2.13, lower left). When I impact the tip of the osteotome, my eyes are usually focused on the proximal tip of the chisel, which receives the impact of the mallet.

Fig. 2.13

Michelangelo’s grip. Upper: part of the “The Young Michelangelo,” 1861, by Emilio Zocchi, white marble, Pitti Palace Museum, Florence (Whole statue; 105 cm). Note the left hand holding a chisel. Lower left: supporting the bottom with the thumb and holding it with the remaining four fingers. Lower right: the distal part of the chisel is supported on the extensor surface of the proximal phalanx of the flexed little finger, and the proximal part is pushed by the palmar surface of the distal phalanx of extended thumb. The index finger, middle finger, and ring finger hold the shaft of the chisel

Recently, I visited the Pitti Palace in Florence, where I happened to see a beautiful marble sculpture of a boy making a facial mask of a Satyr (Faun) using a chisel and mallet. This statue captures the legendary artist Michelangelo as an adolescent (“The Young Michelangelo,” 1861, by Emilio Zocchi, 105 cm; Fig. 2.13, upper).

At the age of 15, Michelangelo entered the Garden of the Medici School of San Marco to study sculpture. When Lorenzo de’ Medici (known as Lorenzo il Magnifico), the school’s founder and patron, came upon Michelangelo replicating an ancient statue of a satyr, Lorenzo was impressed by the youth’s talent but commented that the elderly satyr would not have such perfect teeth. In response, Michelangelo spontaneously took up his chisel and broke off a single tooth from his statue. It was at that moment that Lorenzo understood the talent of the young sculptor and invited him to stay in the Palazzo Medici [22, 23].

In “The Young Michelangelo,” the boy is so concentrated that he has a glabellar frown. His eyes are focused on the tip of the chisel, which is making contact with the raw marble bone. The distal part of the chisel is supported on the extensor surface of the proximal phalanx of the flexed little finger, and the proximal part is pushed by the palmar surface of the distal phalanx of extended thumb. The index finger, middle finger, and ring finger hold the shaft of the chisel (Fig. 2.13, upper). The contact surface of the mallet is concave. It is thought that this grip can transmit the impact of the mallet to the tip of the chisel effectively, because the chisel is held lightly, with less grasping force of the fingers. Therefore, Michelangelo was able to break off a single tooth in front of his patron immediately.

When I returned to my operating theater, I compared these two methods of holding an osteotome and found that the grip portrayed in “The Young Michelangelo” was more stable than the grip I had used. With the improved stability of this grip (Fig. 2.13, lower right), I could focus my eyes on the distal tip of the osteotome, rather than on the proximal tip, which receives the impact of the mallet.

Although I myself had been stuck in a rut, I changed my method of holding an osteotome, and by doing so, I broke the law of inertia.