An excerpt from The Facemaker

ABOVE: © iStock.com, Stephen Barnes

In The Facemaker: A Visionary Surgeon’s Battle to Mend the Disfigured Soldiers of World War I, author Lindsey Fitzharris relates the extraordinary story of medical innovator Harold Gillies, whose dedication to rebuilding the war’s burned and broken faces ushered in the modern era of plastic surgery. At what The Times declared “The Nearest Hospital to the Firing Line” in Belgium, Gillies personally encountered the human wreckage of industrialized war, and on his return to England he established one of the world’s first hospitals dedicated entirely to facial reconstruction. There, he led a multidisciplinary team of doctors, nurses, artists, and orderlies in a series of pioneering procedures. These included the invention of the “tubed pedicle” to increase the success rate of skin grafts; the development of a method that revolutionized the rebuilding of eyelids; and an insistence on repairing underlying facial structures before addressing the restoration of appearance. The Facemaker draws a direct line from this ground-breaking work to revolutionary face transplants being undertaken today. 

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The excerpt that follows details Gillies’s radical approach to rhinoplasty, or nasal reconstruction. This is one of history’s oldest recorded surgical procedures, dating back to 600 BCE, but the existing technique was rendered woefully inadequate by the destructive power of the war’s military technology. Beginning with Private Robert “Big Bob” Seymour, his first “nose job,” Gillies introduced new methods to meet this surgical challenge. 

From Chapter 6, “The Mirrorless Ward” 

Even though rhinoplasty had been around for centuries, existing methods were ineffective in addressing the severity and variety of nasal damage inflicted during World War I. This was especially true if the bridge of the nose or the cartilage had been destroyed, since most older techniques only addressed soft tissue reconstruction through the use of skin flaps. But surgeons discovered that even cases involving flaps could be problematic. 

One patient who found himself in Gillies’s care had first undergone reconstructive surgery in Birmingham [UK]. The rotation flap used to reconstruct the nose had not been supported by a cartilage bridge, so the entire structure had collapsed inward. Additionally, the surgeon had taken the flap from the patient’s forehead but, in doing so, accidentally transplanted part of his scalp onto the new tip. By the time the man reached Gillies, “a sizable tuft of hair” was protruding from his new nose. It took twenty-one operations and nearly five years to correct and improve the defect. 

Soon after Private Seymour’s own arrival at the Cambridge Military Hospital, Gillies handed him an album of different nose types for his perusal. After some consideration, Seymour decided on a Roman nose with a prominent bridge. Over the course of two operations, Gillies rebuilt Seymour’s nose. 

First, he harvested a piece of cartilage from the patient. To establish a blood supply, Gillies wrapped it in a blood-vessel-rich flap of tissue that was folded downward from the forehead. Afterward, this was covered in what Gillies termed the “Bishop’s Mitre” flap—so named because the skin used to cover the site was cut in the shape of a truncated kite resembling a bishop’s hat. Two months later, Gillies was able to advance the flap downward, since the cartilage had produced a satisfactory support for the new tip. 

It was an imperfect first attempt, giving Seymour more of a swollen boxer’s nose than the aquiline profile of a senatorial Roman. But Seymour was so pleased with the outcome that he agreed to become the surgeon’s private secretary after his recovery, a position he held for the next thirty-five years. 

Repairing nasal injuries became a commonplace procedure for Gillies. But one case stood out from all the others. So successful was it that Gillies would later note its significance to the improvement of nasal reconstruction techniques. 

William Spreckley—the eldest son of a lace-maker—was in Germany learning his trade when the war broke out. As he made his way back to Britain, he was stopped by authorities. On account of his fluent German, the men who detained Spreckley mistook him for a German citizen and thought he was attempting to flee the country to avoid fighting. Eventually, Spreckley made it back home to England, where he enlisted in the army and was sent to Belgium. There, he rose to the rank of lieutenant before sustaining the facial injury that would cut short his military service. 

When Spreckley arrived at the Cambridge Military Hospital in January 1917, a large crater occupied the middle of his face where his nose had once been. Gillies met his new patient with the same quiet confidence with which he met all those who came under his care. “Don’t worry, sonny,” he said, despite being only a few years older than Spreckley. “[Y]ou’ll be alright and have as good as face as most of us before we’re finished with you.” 

Gillies wasted no time getting to work. Time was of the essence, given the depth of the gash across Spreckley’s face. First, Gillies applied skin grafts to the raw areas of the wound to ensure that the airways were protected. He then took a piece of cartilage from below one of Spreckley’s ribs and shaped it like an arrowhead so that it would eventually give lateral support to the wings of the nose that form the nostrils. Gillies implanted this into Spreckley’s forehead near the hairline, where it remained for six months. Next, he created a skin-graft inlay to supply a future nasal lining and placed this below the cartilage. After establishing a viable blood supply, Gillies swung the cartilage and skin-graft inlay downward to construct the bridge of Spreckley’s nose. He then covered the bridge with a skin flap taken from the soldier’s forehead. 

Initially, Spreckley’s new nose was gargantuan—three times the size it should be. Where once there had been nothing but a giant pit in the middle of the lieutenant’s face, there was now a bulbous mass of skin and tissue. Gillies likened it to an anteater’s snout: “all my colleagues roared with laughter . . .” Discouraged by the result, Gillies lost faith in the complex technique, vowing never to repeat it. But soon enough, the swelling began to subside, and he was able to remove the excess fibrous tissue around the site. The result was encouraging, as the semblance of a nose began to appear. Gillies wrote, “[H]asty judgment leads often to the discard of the principle the soundness of which may later be proved.” 

As Spreckley’s wounds healed and his nose settled into place, he became one of Gillies’s star cases. “Look at Spreckley today,” Gillies joked later in life. “He and his nose went back to the Army in 1939 and served together until [he left the military in] 1950.” It was a happy ending for both the surgeon and his patient. g 

Lindsey Fitzharris holds a doctorate in the history of science and medicine from the University of Oxford. Her previous book was entitled The Butchering Art.