Plastic Surgery Principles

Plastic surgeons possess unique and versatile skills for reconstructing defects relating to cancer extirpation, cosmetically enhancing normal anatomy, salvaging limbs after trauma, rehabilitating burn patients, ameliorating childhood deformities, and performing autotransplantation as well as allotransplantation. This expertise is also critical in devising creative solutions to a variety of problems faced by physicians in other specialties — for this reason, plastic surgeons are frequently consulted by colleagues across disciplines.

What unifies this enormous breadth of practice is not an anatomic region or patient population, but a shared dedication to fundamental principles. Every plastic surgeon abides by these principles to successfully execute the complex assessments, judgment calls, and technical decisions encountered in daily practice.^[1]

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Ambroise Paré (1564) — The Original Five Principles

The art and principles of surgical reconstruction trace back to 1564 and the famous French barber-surgeon Ambroise Paré, who codified five foundational surgical principles that remain relevant today:^[2]

1. Take away what is superfluous
2. Restore to their places things which are displaced
3. Separate those things which are joined together
4. Join those which are separated
5. Supply the defects of nature

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Sir Harold Gillies — The Ten Commandments (1950)

In 1950, Dr. D. Ralph Millard published Sir Harold Gillies' Principles, commonly referred to as the Ten Commandments of Plastic Surgery. Gillies, widely regarded as the father of modern plastic surgery, distilled his principles from his formative experience reconstructing facial injuries in World War I:^[3]

1. Thou shalt make a plan
2. Thou shalt have a style
3. Thou shalt honor that which is normal and return it to normal position
4. Thou shalt not throw away a living thing
5. Thou shalt not bear false witness against thy defect
6. Thou shalt treat the primary defect before worrying about the secondary one
7. Thou shalt provide thyself with a lifeboat
8. Thou shalt not do today what you canst put off until tomorrow
9. Thou shalt not have a routine
10. Thou shalt not covet thy neighbor's plastic unit, handmaidens, forehead flaps, Thiersch graft, ox cartilage nor anything that is thy neighbor's

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Updated Gillies' Principles (16 Expanded Principles)

The principles Gillies articulated have since been formalized and expanded into sixteen operationalized principles for modern reconstructive practice:^[3]

#	Principle	Commentary
1	Observation is the basis of surgical diagnosis	A keen sense of observation is invaluable in making an accurate diagnosis
2	Diagnose before you treat	A problem should be accurately determined before proceeding with an operation
3	Make a plan and a pattern for this plan	Preoperatively establish a goal and develop a method; intraoperative improvisation is expected but cannot substitute for a preoperative plan
4	Make a record	Accurate records assist with coordinating care and provide medicolegal protection
5	The lifeboat	Anticipate possible difficulties; devise a secondary plan in case the primary plan fails
6	A good style will get you through	Surgical style is "the expression of personality and training exhibited by the movements of the fingers" — develop a style but remain able to modify it
7	Replace what is normal in a normal position and retain it there	Surgical reconstruction requires recognizing what is normal in order to restore displaced parts to their correct place
8	Treat the primary defect first	Concern with secondary defects must not impede treatment of the primary defect
9	Losses must be replaced in kind	Like should be replaced with like (e.g., hairless skin with hairless skin); when exact replacement is unavailable, the closest substitute is used (e.g., urothelium with buccal mucosa)
10	Do something positive	When faced with a complex intraoperative problem, taking any constructive step toward the solution is vital
11	Never throw anything away	In reconstructive surgery, never discard tissue unless certain it is not needed
12	Never let routine methods become your master	Master routine methods, but remain open to advancement and innovation
13	Consult other specialists	Collaboration allows dissemination of solutions across specialties and improves patient care
14	Speed in surgery consists of not doing the same thing twice	Doing things right the first time is more efficient than correcting errors
15	The aftercare is as important as the planning	Appropriate postoperative monitoring and care is crucial — and in some cases more important than the surgery itself
16	Never do today what can honorably be put off until tomorrow	When danger or doubt is associated with a surgical maneuver, consider whether the decision may be deferred for a safer time

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Millard's 33 Commandments of Plastic Surgery

D. Ralph Millard Jr. — Gillies' most celebrated trainee and the originator of the rotation-advancement repair for cleft lip — expanded these principles into 33 commandments organized across five domains:^[4]

Preoperational Principles

1. Correct the order of priorities
2. Aptitude should determine specialization
3. Mobilize auxiliary capabilities
4. Acknowledge your limitations so as to do no harm
5. Extend your abilities to do the most good
6. Seek insight into the patient's true desires
7. Have a goal and a dream
8. Know the ideal beautiful normal
9. Be familiar with the literature
10. Keep an accurate record
11. Attend to physical condition and comfort of position
12. Do not underestimate the enemy

Executional Principles

13. Diagnose before treating
14. Return what is normal to normal position and retain it there
15. Tissue losses should be replaced in kind
16. Reconstruct by units
17. Make a plan, a pattern, and a second plan (lifeboat)
18. Invoke a Scot's economy
19. Use Robin Hood's tissue apportionment
20. Consider the secondary donor area
21. Learn to control tension
22. Perfect your craftsmanship
23. When in doubt, don't

Innovational Principles

24. Follow up with a critical eye
25. Avoid the rut of routine
26. Imagination sparks innovation
27. Think while down and turn a setback into a victory
28. Research basic truths by laboratory experimentation

Contributional Principles

29. Gain access to other specialties' problems
30. Teaching our specialty is its best legacy
31. Participate in reconstructive missions

Inspirational Principles

32. Go for broke
33. Think principles until they become instinctively automatic in your modus operandi

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Modern Principles of Plastic Surgery (Grabb & Smith, 8th ed.)

The most current comprehensive framework, codified in the standard textbook of the specialty:^[1]

Principle	Statement
I	Make an informed decision to operate or not operate
II	Optimize modifiable patient factors
III	Perform adequate debridement prior to reconstruction
IV	If possible, replace like with like; if not possible, create it
V	Optimize vascularity at every opportunity
VI	Preserve form and function
VII	Minimize donor site morbidity
VIII	Protect the surgical site postoperatively
IX	Have a backup plan (and a backup plan for that backup plan)
X	Innovate new solutions to old problems

Technical Corollaries for Reconstructive Surgery

Reconstructive surgery is performed with all efforts aimed at minimizing tissue injury and promoting healing.^[1]

Suture selection: The caliber of suture should be the smallest possible to align tissue tension-free — there is no benefit to using suture stronger than the tissue being approximated. For flap or graft repair, 4-0 to 6-0 suture is generally adequate. For primary anastomosis of the corpus spongiosum and urethra, or for posterior urethral reconstruction, 3-0 and 4-0 suture is appropriate.

Tissue mechanics: All tissue has physical characteristics that must be respected during reconstruction:^[1][5]

• Extensibility — the maximum stretch of tissue before plastic deformation
• Inherent tension — the resting tension within unloaded tissue
• Stress relaxation — under constant strain, tissue tension decreases over time (exploited in tissue expansion and intraoperative stretch)
• Creep — under constant load, tissue gradually elongates over time

These viscoelastic properties are primarily a function of the helical arrangement of collagen and elastin cross-linkages within the dermis and subcutaneous tissue. Understanding and exploiting them allows surgeons to close defects that initially appear impossible.

:::note Principle IX in Urethral Reconstruction Principle IV ("replace like with like") and Principle IX of the updated Gillies framework directly underpin urethral surgery: urothelium is ideally replaced with urothelium; when that is unavailable, buccal mucosa is the closest available surrogate — sharing similar non-keratinizing properties, robust submucosal vascularity, and resistance to the wet environment of the urinary tract.^[1] :::

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References

1. Gurtner GC, Neligan PC, eds. Plastic Surgery. 4th ed. (formerly Grabb & Smith's). Elsevier; 2017. [Grabb & Smith's 8th ed. principles referenced in user content — see also current edition for updated frameworks]

2. Paré A. Œuvres d'Ambroise Paré. Paris; 1564. Historical reference cited in Losee JE, Gimbel ML. "Principles of Plastic Surgery." In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. Elsevier; 2022.

3. Gillies H, Millard DR. The Principles and Art of Plastic Surgery. Vol. 1. Boston: Little, Brown and Company; 1957.

4. Millard DR Jr. Principalization of Plastic Surgery. Boston: Little, Brown and Company; 1986. [PMID reference for Millard's commandments framework]

5. Daly MJ, Davies DM. Biomechanics of skin. In: Neligan PC, ed. Plastic Surgery. 4th ed. Vol. 1. Elsevier; 2017.