The Reconstruction of Plastic Surgery: A Historical Perspective on the Etymology of Plastic and Reconstructive Surgery

Abstract

Although the origins of procedures now falling under the scope of modern plastic surgery date back thousands of years, it was only fairly recently that these were grouped under the umbrella term “plastic” surgery. However, mainly due to the industrialization period, the popular understanding of the term “plastic” would soon change—making way for the addition of the term “reconstructive” to the specialty's name. Through a careful look at historical trends, the authors illustrate how this unintentionally led to an ideological divide between the aesthetic and reconstructive portions of our work, prompting a recent push to unify the field under the one, original, lexical choice: “plastic” surgery.

Background

Dating back to ∼600 B.C. India, with the origins of the forehead flap for nasal reconstruction described in Sushruta's Samhita text, surgeons have been performing reparative procedures falling under the scope of modern plastic surgery. ¹ It was not until 1838 that these procedures were distinctly designated as “plastic” surgery by Eduard Zeis, alluding to the Greek adjective Plastikós, meaning moldable.^2,3 Since then, the name was fixed to the specialty. Yet one is left to wonder as to why other lexical options with similar meanings were not initially used, namely the term “reconstructive.”

Following the industrial revolution and the advent of synthetic plastics, leading to its now ubiquitous use in daily life, the public perception of the term “plastic” naturally evolved. In fact, when looking up the adjective “plastic” in the Merriam-Webster dictionary, the first definition is “made or consisting of plastic,” which demonstrates this change and potentially hints at the many misconceptions presently associated with the specialty of plastic surgery in popular culture. ⁴ “Capable of being molded or modeled” is the third on the list, showing how this definition has lost some attention over the years. ⁴ Following the rise of synthetic plastics, the name of the specialty evolved to include the term “reconstructive,” likely in an effort to reconcile the work being done by plastic surgeons with the concept behind the specialty's original name. This, however, hypothesized to be due to the concurrent rise in aesthetic surgery, led to much confusion by the public and our medical colleagues. The attribution of the term “plastic surgery” was increasingly linked to solely aesthetic procedures, devaluating many of the reconstructive procedures performed by these same surgeons. On the other hand, the term “aesthetic” originates from the Greek word aisthetikos, meaning perception of the senses. It has then been linked to the philosophical study of beauty and taste, and later appropriated by plastic surgeons to describe their work to “reshape normal structures of the body in order to improve the patient's appearance and self-esteem.” ⁵

The authors, therefore, aim to promote the diverse and unified scope of plastic surgery, including both aesthetic and reconstructive procedures, by highlighting the importance of the specialty's name in this endeavour. Herein, the etymology of plastic surgery is concisely explored; beginning with its historical origins, navigating through changes during the industrialization period, with a final note on the contemporary state in the specialty's designation.

Origins

Plastic surgery is one of the oldest surgical specialties, as in its beginnings the practice of surgery was commonly limited to the body's surface, tailoring to external lesions or injuries and the alleviation of wounds, which are all under the scope of contemporary plastic surgery. ⁶ There are even many allusions to it in Greek mythology, such as the depiction of Achilles providing wound management for Patrocleus’ arm during the Trojan war and the story of Hermes suturing the tendons of Zeus’ hands and feet back together after being avulsed during the battle of the Titans. ⁷ As the complexity and breadth of procedures performed by surgeons evolved throughout the 18th century, their education moved away from the conventional apprenticeship-based approaches and evolved into didactic and book-based learning. ⁸ That is when surgeons became on par with their medical counterparts in terms of academic and professional standing and allowed for the creation of universal frameworks and schools for surgery. ⁶ It is this academically inclined shift that then facilitated the creation of specific expertise, and prompted the division of surgery into distinct subspecialties.

Since surgeons were historically concerned with the surface of the body, this allowed for many procedures now falling under the scope of modern reconstructive plastic surgery to originate far before other surgical procedures still used today. These include nasal reconstruction with forehead flaps which finds its roots in ancient India in 600 B.C., and cleft lip repair and advancement flaps in ancient Rome in 30 A.D. in Celsus’ De Medicina, in addition to wound care.^1,9 The true beginning of plastic surgery as a distinct scientific medical endeavour, however, is often associated with Gaspare Tagliacozzi's De Curtorum Chirurgia per Insitionem in 1597, due to his systematization of procedures, especially nasal reconstruction, and the text's widespread dissemination made possible by the invention of the printing press.^10,11 From a historical perspective, the difficulty of the operations and the rise of prosthetics rendered these procedures obsolete, until the nasal reconstruction technique was later refined and published in 1816, keeping in line with the pedagogical shift of surgery occurring across the Western world.^12,13

Although the term “restoration” was being used to describe these procedures, only 2 years later, Carl von Graëfe published the landmark text Rhinoplastik, in which he describes his experience with nasal reconstruction, which—more importantly—marked the first time in history the term “plastic” was associated with reconstructive procedures.^3,14 This was then followed by Eduard Zeiss’ naming of the specialty as “Plastische Chirurgie”—plastic surgery—in 1838. ² It has been argued that at that time, the term “plastic” had deep philosophical and artistic connotations, based on its Greek root signifying malleability. ³ Although this name would then adhere to the specialty, the popular understanding of the term “plastic” would soon be drastically altered.

The Reconstruction of “Plastic”

The industrial revolution brought on many changes to society at the time, by rendering the manufacturing of goods in large quantities now a feasible endeavour. This led to an unprecedented and exponential growth in trading and population numbers, although soon constrained by the limited quantity of natural resources. This fueled scientists to create new materials toward the end of the 19th century, namely with the creation of the first plastic material and the first fully synthetic plastic.^15,16 The adoption of these came at a swift rate, especially with their associated cost savings during both World Wars, and the industrialized world that followed. With this, the term “plastic” came to be widely used to describe these newly discovered polymers, now ubiquitous in society.

Interestingly, it was not long after the creation of plastic material, especially following the first World War where its industry saw a large increase in production, that the term “plastic and reconstructive surgery” began to appear in the medical literature. It is first found as the title of a piece published in The Hospital in 1919 describing the recent advances in craniofacial reconstruction after the Great War, in which the author curiously uses the term “restorative surgery” and “plastic surgery” to describe the procedures in the text, rather than using the term “reconstructive.” ¹⁷ This comes to no surprise as the term “reconstruction” was still not widely used in this manner. Following, the American Society of Plastic and Reconstructive Surgery was created in 1931, and in an article published in 1947 by Dr. Maliniac recounting the foundation of the Society, the desire for “a more comprehensive title” seems to be the motivating factor behind the addition of “reconstructive” to their official name. ¹⁸ This allowed for a less restricted membership, which was especially important at the time considering the exponentially growing breadth of procedures and surgeons interested in the field, following the myriad of facial injuries sustained on the battlefields of the first and second World War. Namely the contributions of Sir Archibald McIndoe and Harold Gillies regarding the treatment of burns sustained by the Royal Air force pilots, later termed the “Guinea Pig Club,” are paramount to mention in this concern. ¹⁹ At this time, burn surgery was in its infancy, and its innovations continued pushing the boundaries of plastic surgeons’ breadth of expertise.

This naturally led to the creation of the Society's journal Plastic and Reconstructive Surgery, which is in fact still its primary journal to this day. ²⁰ Internationally, other societies were also attempting to address this change in perception of the term “plastic” by proposing new names for the specialty. For example, the first supranational society naming itself the Société Européene de Chirurgie Structive and the French society Société Française de Chirurgie Réparatrice Plastique et Esthétique.^21,22 The terms “structive” and “reparative” soon faded out; as due to its allying with prominent domestic and international surgeons, the readership of Plastic and Reconstructive Surgery expanded rapidly and the widespread acceptance of the American Society of Plastic and Reconstructive Surgery's annexation of the term “reconstructive” was soon to follow. ¹³ In fact, the Canadian Society of Plastic Surgeons has in the past prompted the Royal College of Physicians and Surgeons to add the term “reconstructive” to its official name. ²³ Nevertheless, this term was rarely used on its own by plastic surgeons at the time, as it was often used by others to describe surgeries that did not fall within their existing scope of practice, such as urogynecological and orthopedic reconstruction.^24–26

Misperception

Around the same time that the term “reconstructive” was gaining acceptance from the plastic surgery community, aesthetic surgery began to see a rapid and widespread expansion in modern-day society. ²⁷ New and improved techniques were being devised, while public acceptance grew larger for cosmetic procedures, that were in fact largely and rightfully appropriated by plastic surgeons.^13,28 As their scope of practice now included both aesthetic and reconstructive procedures, a nuance with their newly appointed title began to arise. The public began to associate the term “plastic” in the context of surgery with cosmetic procedures, as reconstructive procedures were different and were accounted for under the term “reconstructive” in the specialty's double name. ²⁹ This was and is still largely driven and perpetuated by the media. ³⁰ As well, with the now popular association of the term “plastic” to artificial or synthetic materials and their use, namely silicone, in some cosmetic procedures, the association of “plastic surgery” to aesthetic endeavours resonated with the layperson.

This has, unfortunately, led to much frustration from the plastic surgery community, as their specialty was increasingly viewed in a negative and misconstrued light, from both the public and their medical colleagues.^31,32 The association of plastic surgery with solely cosmetic, nonmedically indicated procedures has led to its devaluation in the public eye, as being ranked last out of 30 specialties in terms of importance in providing care for patients in a hospital in a recent study. ³³ Considering the hefty financial compensation for cosmetic procedures, the media has also often portrayed plastic surgeons as strictly business-oriented, implying a certain degree of disregard for their patients’ health and wellbeing. ³⁴ As well, due to the predominance of aesthetic surgery among plastic surgeons and its popularization in the media, the public and even other physicians often lack a true understanding of the scope of reconstructive surgical problems that fall under the plastic surgeons’ purview.^30,35,36 For instance, in a recent public survey in the United States, 69% of respondents believed hand/finger fractures were under the predominant expertise of orthopedic surgeons, while only 18% felt plastic surgeons had the requisite qualification to address such conditions. ³⁵

Back to the Roots

Although some might relinquish this to semantics, it was to avoid promoting a firm divide between aesthetic and reconstructive procedures both performed by plastic surgeons, that many advocated changing the name of their largest society. ²⁹ It was felt that a clarification was needed, mainly for the purpose of reconciling all subspeciality domains under the all-encompassing umbrella of “Plastic Surgery.” This thereby emphasized cooperation in research and education, in addition to building a more positive public image for the specialty, as names have been shown to have a meaningful impact from a psychological perspective.^37,38 By 1999, the American Society of Plastic and Reconstructive Surgeons in fact changed its name to the American Society of Plastic Surgeons. ³⁷ This was largely met with support from their constituents and met with many calls for plastic surgeons to proudly defend both the aesthetic and reconstructive portions of their work, that fall under the common umbrella of “plastic surgery.” ²⁹ This has also been demonstrated in the more recent creation of a journal for the Canadian Society of Plastic Surgeons named Plastic Surgery.

However, there is still much work to be done, as searches of PubMed title and abstracts show that in the Plastic and Reconstructive Surgery Journal, which is the official journal of the American Society of Plastic Surgeons, the term “plastic and reconstructive surgery” was used 17,722 times since 2000, while “plastic surgery” was only used 7192 times. There is nonetheless an overall increase in the use of the term “plastic surgery” in the journal in recent years, compared to a plateau in the term “plastic and reconstructive surgery.” This highlights the gap that has yet to be bridged in the endeavour of unifying all branches under the common name of “plastic surgery,” with an ultimate goal of improving its public perception. There exists encouraging data, however, as an analysis of the studies published in the Canadian journal show that the term “plastic and reconstructive surgery” was used 129 times since 2003, while “plastic surgery” was used 416 times.

The authors believe it is important to continue striving toward this goal, by for example publicizing the reconstructive aspects of plastic surgery on par with its cosmetic counterpart, as studies suggest a large portion of the population and our medical colleagues are unaware of the broad scope of practice in plastic surgery, even possibly leading to a decrease in referrals and appropriate medical care.^30,35,36 As terms such as “restorative surgery” reappear on the horizon, plastic surgeons must make no compromises in staying unified under the umbrella term of “plastic surgery,” as a look into the history of its etymology has clearly shown the repercussions otherwise. ³⁹

Rather than assert what the naming of the specialty must be, the authors’ main goal was to stimulate discussion on this topic, with the understanding that valid differing views exist. For example, some may plausibly argue that adding the term “reconstructive” has helped clarify to the public what plastic surgeons really do, given that the term “plastic” has become part of other subspecialties’ designations (eg, facial plastic surgery, oculoplastics, etc). In fact, this belief in the lack of specificity of the term “plastic” is common among plastic surgeons, as many choose to call themselves by their subspecialty's name (eg, hand surgeon, craniofacial surgeon, etc).

Conclusion

Although the origins of the specialty of plastic surgery date back to ancient times, it only received the name “plastic” in the mid-19th century, with a basis in the Greek word Plastikós signifying malleability. With the rise of synthetic plastics and the surge in need for plastic surgery procedures around the time of the World Wars, it was felt that adding the term “reconstructive” to the name would help mitigate the new public perception of the term “plastic.” Largely due to the following rise of aesthetic surgery, this led to more confusion among public perception, and eventually prompted many plastic surgeons to a reappropriation of the sole encompassing term “plastic” to describe their work. Further studies are needed to examine the long-term perceptible implications of this lexical choice.