Modern facial surgery owes much to Kiwi wartime medical pioneers

by Ruth Nichol / 28 May, 2015

The techniques and materials Dunedin face and jaw surgeon Darryl Tong uses in the operating theatre are very different from those pioneering New Zealand surgeon Harold Gillies used to treat soldiers with serious facial injuries during World War I. Unlike Gillies, Tong doesn’t stitch up wounds with catgut or horsehair, nor does he have to rely on medieval-looking dental devices to fix everything in place and hold the bones rigid. Instead, he uses high-tech metal plates and screws. Infection is not a constant fear either – antibiotics have long since put paid to that.

But Tong, who teaches at the University of Otago Dental School and is also a member of the New Zealand Army Reserve, is impressed by the fact that the surgical principles established by Gillies a century ago remain true today. “Gillies realised that you need to wash out the wound properly and remove any dead tissue, then close it up layer by layer, which decreases the tension at skin level and minimises the scar.”

He’s just as impressed by the wartime medical achievements of three other men with New Zealand connections. The most famous is Gillies’ cousin Archie McIndoe, a graduate of the University of Otago Medical School who helped revolutionise burns treatment for RAF pilots during World War II. Less well known are Henry Pickerill, the first dean of the Otago Dental School, and Auckland-born Rainsford Mowlem. Pickerill worked alongside Gillies at Queen Mary’s Hospital in Sidcup during World War I, carrying out some of the world’s first successful bone grafts. Mowlem helped develop more sophisticated bone-grafting techniques while treating facial injuries at a London hospital during World War II.

“You can change the skill set and the equipment and the operator, but the rules don’t change – that’s the true gift these men have given us in the modern age,” says Tong, who recently completed a PhD in face and jaw surgery in warfare.

He says soldiers have always tended to suffer injuries to the head, face and neck, and even the most sophisticated modern combat body armour can’t completely protect the face. But the use of trench warfare during World War I meant surgeons found themselves dealing with an unprecedented number of what are known as maxillofacial injuries. “When you pop your head above the parapet, you’re at risk of ballistic injuries from machine guns and shrapnel,” says Tong.

Facial injuries were less common during World War II – possibly because the style of warfare was more mobile – but burns were a problem, particularly for air crew who often ended up with horrific injuries when their planes caught fire. Many were treated by McIndoe, who established the famous Guinea Pig Club at Queen Victoria Hospital in East Grinstead. He helped develop many of the principles of burns treatment that are used today. They include using saline bath immersions (rather than tannic acid) as an initial treatment, as well as getting rid of dead tissue and carrying out skin grafting as soon as possible.

Thanks to McIndoe, rehabilitation – both physical and psychological – also became an integral part of the treatment process. East Grinstead became known as “the town that never stared” after McIndoe – a forceful personality – insisted that residents interact with his sometimes frightening-looking young patients. “That holistic way of managing trauma victims, which people think is modern, may have started with Gillies, but it was really formalised with ­McIndoe,” says Tong.

As the ancient Greek physician Hippocrates observed, if you want to be a surgeon, you should go to war. There’s no doubt that war provided Gillies, McIndoe and many other surgeons with extraordinary opportunities. Gillies, for example, carried out more than 11,000 operations during World War I and would have encountered almost every possible kind of facial wound. So it’s probably not surprising that he helped pioneer groundbreaking new surgical techniques, such as the use of tube pedicles to provide infection-resistant skin for skin grafts.

But Tong likes to think that something uniquely Kiwi was at play too. “I think it has something to do with the New Zealand attitude, the No 8 fencing wire mentality that permeates all levels of our society.”

For a review of In Love and Warm which looks at Archie McIndoe's work, see here.

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