Blood and Guts: A History of Surgery (2008) s01e04 Episode Script
Fixing Faces
1 In 1903, society beauty Gladys Deacon had hot paraffin wax injected directly into her face.
In 2006, Isabelle Dinoire had a partial face transplant.
What separates these two women .
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is 100 years of developments in plastic surgery.
Can I have the knife? My name is Michael Mosley, and when I was a young medical student, what I really wanted to be was a plastic surgeon.
That's because what surgeons can do, particularly with badly damaged faces is both awe inspiring and heart rending.
You had the tube there hanging like a trunk It's a 2,500-year journey.
From the earliest surgery, to 20th-century pioneers.
THEY SING In this programme, I'm going to lead you down the long, dark road that surgeons stumble along to take us to where we are today.
That's me on you.
Agh! Good Lord! How much does the look of a human face really matter to us? Using this brain scanner, I'm about to find out.
By allowing it to read my mind.
We're just about ready to get started here.
Everything OK with you?Yep, fine.
As I lie locked inside the core of an electro-magnet, a series of faces are projected onto a screen.
At first, they're ordinary, normal faces.
But then they become disturbing, damaged.
There are some pretty horrific images in there.
Difficult, aren't they?Oh I mean Yes! I try to control my feelings, but the brain scan is going to reveal my true reactions.
OK, so that's the end.
I'll just come in and get you out, OK? Oh! Oh, that really was quite quite disturbing.
I'll be very interested to see what the reaction of my brain is, because as I was lying looking at some of those faces, I thought, "Oh, dear.
Oh, dear.
Oh, dear.
" OK, this is essentially my lovely brain here? That's right.
That's it there.
Very nice looking brain.
This is a snapshot taken during the experiment.
The green spot shows unusual activity in the amygdala, a primitive part of the brain that processes fear and disgust.
The amygdala is associated with a lot of the negative responses.
Right.
If we look at the response, this is how much stronger your response was to those disfigured faces than the normal faces.
The normal face response was no different from base line.
Right, so basically, this is insignificant and that's big?Yes.
So essentially, what's happening here is I'm having a big negative, possibly disgust response to the faces I'm looking at.
Right.
But this would be pretty much a normal human reaction to a distorted face.
You seem like a normal human being! Thank you very much.
Sometimes, I wonder! But it is very, very striking.
They were disturbing, but I was trying to feel compassionate.
But generally, it looks like my reaction was negative.
Yeah.
I was strongly emotionally negative.
Right, exactly.
Which is a shame, cos I like to think of myself as a compassionate guy, but it seems to be Well, like I said, I suspect you felt compassion.
You also felt that negative, natural response that people feel to these sorts of faces.
I'm slightly ashamed, cos I sort of thought I would be able to control my emotions more.
But it didn't happen like that.
No.
How fascinating.
Really interesting, thank you.
That was really interesting.
When you see just how profoundly the brain responds to disfigured faces, you can understand - if you looked like that - how much you might want to change.
Our unfortunate reaction to disfigurement seems to be deeply engrained, and it's certainly not new.
Attempts to surgically alter how people look have been going on for millennia.
The Hindu poem Ramayana was written about 3,500 years ago.
It tells the story of Surpanaka, a temptress found guilty of infidelity.
Her punishment was brutal.
She lost her nose.
The practice of cutting off a nose as a form of punishment went on in India well into the 20th century.
But what really interests me about this particular poem is what happened next.
Our seductress, having had her nose chopped off, immediately went for reconstructive surgery.
The poem doesn't say how it was done, but there's a clue in an Indian medical text written in 600BC.
The technique described was clever, and it featured a fundamental principle of reconstructive surgery that would be used right up to the 20th Century.
Clever, but not pain free.
2,500 years before the discovery of anaesthetics, the operation would start with a knife to the forehead.
As I'm demonstrating with this very realistic model.
It's a searing 5mm cut down to the periosteum.
A membrane which covers the skull.
Right.
Well, I've got there, now I've got to tweak it up.
I cannot imagine what it would have been like to do this on a living, breathing, screaming human being.
I've now reached a critical stage.
What I really don't want to do is break off this.
This is what the Indians called a pedicle, because if I just took a piece of tissue here and just cut the whole thing off and stuck it on the nose, this would die, because the area here is rich in blood vessels, and what you want to do is try and preserve them.
What I'm going to do, I think you can see now, is lift it up.
Give it a little bit of a twist.
And I think you can see the formation of a new nose.
Isn't that wonderful? This pedicle has still got a good blood supply.
And that will bring life to this nose.
The Indians knew nothing about the circulatory system, but they did realise that without an adequate blood supply, any tissue they mobilised to create a new nose would swiftly die.
When you think that they were doing this 2,600 years ago, I think that is quite remarkable.
This, this is the beginning of reconstructive surgery.
Surpanaka got her new nose, but it would have been at the expense of bearing a hideous scar on her forehead.
It was a problem that wouldn't be addressed for over 2,000 years.
Fast forward to Renaissance Italy and Bologna .
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home to a surgical pioneer who would try a rather different approach to nasal reconstruction.
In 16th-century Bologna, there was not only an explosion of art and science, but disease.
Syphilis, a hideous sickness that is thought to have been imported from South America.
It turned its victims into social pariahs.
Identified as moral degenerates by their lack of a nose.
But here at the University of Bologna medical school, a radical new treatment was about to emerge.
The man who inspired it was Gaspare Tagliacozzi.
His declared mission was to bring back, re-fashion and restore to wholeness the features which nature gave, but chance destroyed.
Tagliacozzi experimented with all kinds of facial reconstructive surgery, but in particular, noses.
His method for repairing nasal collapse was based on work originally done in Sicily, and it was inspired.
Plastic surgeon Paolo Santoni-Rugiu has studied how he did it.
They made two parallel incisions.
Blimey, did that hurt?No Yes! It was very quick, just like this.
Just like that.
Then he undermined the skin so it was loose.
Right.
So he had something like this.
That was the pedicle.
After two or three weeks, it attached to the nose.
Oh, right.
How?Like this.
Cor.
Very complicated.
Very complicated and not very comfortable.
The blood supply was coming from the lower pedicle.
And also through the scar that was produced on the nose.
Right, so he's got to wait for the blood supply to re-grow in the nose bit before he can cut off the arm bit?Yes.
'Before your new nose could be reconstructed, 'you had to hold your arm like this for at least two weeks.
'Fortunately, Tagliacozzi had an answer' A surgical straight jacket.
His design is lovingly detailed in this 16th-century illustration.
And I'm about to try one on.
This jacket was essential for a successful surgical outcome.
The transplanted skin flap had to remain attached to the arm until new blood vessels had time to grow from the stump of the nose and into the skin.
And that meant waiting.
And waiting.
After a week or more of bed rest, patients were allowed to get up and move around.
It's difficult to actually see if people are staring, cos I've got a limited view underneath my arm pit.
It is uncomfortable and embarrassing.
And it speaks volumes about the stigma of syphilis that anyone thought this was worth going through.
And the jacket was only part of his bizarre treatment plan.
Tagliacozzi was extremely interested in nutrition.
In fact, he recommended patients - both before and after this particular operation - totally abstained from eating fish.
If they must eat meat, it should be roasted and not boiled.
Two hours in, and I'm starting to feel the strain.
Ooh It's really quite uncomfortable, I must admit.
Ooh Even more uncomfortable than I thought it was gonna be.
Aah The bit which really gets me is in the neck here, because what's happening is the whole weight of my forearm is resting on this, which is driving my head remorselessly forward.
Very, very uncomfortable.
I've had it on for a short period of time, but I can already feel my neck going.
I think I have had enough.
I'm cold, my neck really aches Trying to get this out.
Oh, God that's better! I only had to wear it for a relatively short period of time.
I just cannot imagine keeping this on for a couple of weeks, let alone any longer.
The straight jacket may be off, but my imagined nasal reconstruction has hardly begun.
To find out what happened next, I've come to Bologna's magnificent biblioteca scientifica.
In here, there is a copy of Tagliacozzi's 1597 masterpiece.
The first ever book on reconstructive surgery.
And it clearly shows the next stage of the Italian nose job.
Well Here, you can see There is the operation where the flap is attached to the nose.
And you can recognise the awful position.
So after two or three weeks, you separate the flap and the nose from the arm.
And you remove this apparatus.
And you will have this piece of skin hanging from the nose.
And you leave this flap hanging.
It's not very attractive looking.
It's not very attractive nose.
Once you start remodelling, it is done mainly with splints, and this lasted at least two months.
Does he have a final picture showing the happy patient at the end? Oh, yes.
Hurrah! You can see the scar.
And a very pretty nose.
And the nose is pretty, yeah.
It certainly shows the power, doesn't it, of a picture? Because if I was a patient and the doctor came and showed me that, I would go, "Yes, please.
" But the reality was probably not as spectacularly good as that.
But it certainly had a big impression, this book.
Oh, yeah, it's still today, or certainly, it was for sure until 25 years ago, the main method of repair to transfer skin from one part of the body to another.
The start of modern plastic surgery is this.
But Tagliacozzi's fame was short lived.
When he died two years later, his reputation collapsed.
The Italian church summoned its religious investigators, the tribunal of the inquisition.
Because Tagliacozzi had modified the human face, he was accused of interfering with God's will.
Although posthumously exonerated .
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stories persist that his bones were dug up and dumped on unconsecrated ground.
For the next 200 years, his successors experimented with a variety of reconstructive techniques.
From tie-on noses .
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to attempts at rebuilding hair lips.
Until the 19th century, almost all facial surgery was reconstructive surgery.
The repair of damaged and diseased faces.
But in the mid-19th century, something new occurs.
Cosmetic surgery.
The attempts to take perfectly normal people and make them more beautiful.
Aaaagh! The discovery of anaesthetics in the 1840s was a huge factor.
Now, if you wanted to look better or younger, you could be almost sure that it wouldn't hurt too much.
With the discovery of anaesthetics, and also cleaner operating theatres which meant there was less risk of infection, facial surgery really became fashionable again.
But this time, instead of using skin and flesh, they tried inserting a range of other strange substances.
Ivory.
Gutta-percha, which is actually the sap from a tree.
And if you warm it up, it becomes soft, and you can use it in the nose.
And this, which I think is really disgusting, it's animal cartilage.
They would use this to try and repair the nose.
One surgeon was so desperate, he actually brought a duck into the operating theatre, slit its throat, removed the breast bone and tried using that to repair his patient's nose.
It failed, of course.
Despite repeated failures, demand for cosmetic procedures at the end of the 19th century absolutely soared.
The surgeons' materials may have been risible, but one in particular became notorious.
And this is it - paraffin wax.
One of the great inventions of the late 19th century.
At room temperature, it's a solid.
But when you heat it up, it goes into a liquid.
And in the liquid form, they would inject it into your face, your buttocks, even into your penis.
It was superb stuff, because as it cooled down, the surgeons could really manipulate and shape it.
What could possibly go wrong? In 1903, society beauty Gladys Deacon heard about the new craze.
Gladys would go onto marry the Duke of Marlborough and install herself in Blenheim Palace.
But the thing she's now really famous for is what she did to her nose.
A nose she hated.
Gladys obsessively toured round galleries, looking at faces, eyes, lips, but particularly noses.
In Edwardian England, neo-classicism was all the rage.
And it was amongst the contours of Classical sculpture that Gladys discovered THE perfect nose.
A nose she decided to have sculpted with paraffin wax.
Now, even the British Medical Journal had enthused about the new wonder treatment .
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detailing its use on the bridge of the nose as "simplicity itself "with an immediate and excellent result.
" A result which left no scar and avoided the need for invasive surgery.
Gladys was sold.
But the procedure was not exactly pain-free.
Well, not for the patient anyway.
The doctor would have worn protective gloves when holding the syringe, as it was heated way beyond the melting point of wax to prevent hardening inside the chamber.
After nicking the entry point with a scalpel .
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hot wax was delivered straight into the nose.
Once inside, there was 30 seconds before it hardened.
30 seconds to mould the perfect nose.
But perfection was not what Gladys got.
Soon after the injections, the wax began to wander.
Gladys' face was mutating.
Her looks were being destroyed.
And she was not alone.
Others had noticed that wax often hardened and clumped after being injected.
Sometimes leading to open sores.
People went blind.
Some got blood clots in the lungs.
Others, necrosis at the injection site.
The flesh just withered and died.
Gladys' condition was quickly labelled paraffinoma, though many called it wax cancer.
It's said she would later sit by the fire in Blenheim Palace letting the heat soften the paraffin beneath her skin, so she could move it around her face.
Still searching for the perfect nose.
You'd have thought that cases like that would have put people off.
But far from it.
Having failed with paraffin wax, people moved on to new materials.
Olive oil, Vaseline, glycerine boiled in carbolic acid, and later, the hugely disastrous industrial silicone.
It seems the pursuit of beauty through a needle was simply irresistible.
The most popular cosmetic procedure is still injections in the face.
But these days, they're not using anything as crude as paraffin wax.
No.
They're using instead a neurotoxin, which is derived from a particularly unpleasant form of food-poisoning bacteria.
Clostridium botulinum.
More commonly known as Botox.
Clostridium botulinum, from which the brand name Botox is derived, is one of the most poisonous substances known.
If evenly dispersed and inhaled, a single gram would kill more than a million people.
In the 1960s, a milder version, the so-called Type A toxin, was first used to treat people with facial ticks.
A cosmetic wonder drug had been born, albeit by accident, and I'm about to try it.
Dr Ross Perry is going to make me a member of the Botox generation.
It's very curious, isn't it? The idea of using something which I read is apparently, the mostpoisonous substance in the known universe, or whatever.
It's, erm The doses that we're using are extremely small to get the sort of reactions that you are sort of talking about.
Tens of thousands higher than this, so Unlikely, even if I inhaled huge amounts of it, that it's going to do anything.
If you drank the bottle, you'd get a little bit of diarrhoea.
I don't think we're gonna do that! Do you do guys my age commonly, or not? Erm, guys your age would have already Most of my patients would have probably already have had some You're really groping for some sort of euphemism there, I can see.
Certainly, we do get patients of your age.
Erm However, we've got to, obviously, consult them with regard to what the perceived outcome is likely to be.
And what is the perceived outcome likely to be in my case?You will notice some benefit, but obviously, it's not going to be as beneficial as if you'd been five, ten years younger.
It's a bit late now, is it? My creases are set in their ways.
They're a little bit deeper.
Your skin is a little bit more lax, and as a result, we can't give you the same volume in the same areas without possibly causing a few side effects.
But worth giving it a go anyway.
In your case, I don't see any reason why not.
No.
Even the refined Type-A toxin is potentially dangerous.
Ross uses an almost undetectable quantity, which he then dilutes in saline.
It will be delivered to me in 23 separate injections.
OK.
Really, we're just injecting points In its natural deadly form, Clostridium botulinum kills by paralysing the muscles of the heart and lungs, and causing paralysis is exactly what the milder Type-A toxin should do.
Though hopefully, will only affect the small muscles in my face.
I read somewhere that the CIA tried to assassinate Castro, apparentlyReally? .
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not I think, by giving him Botox, but by sticking the botulinum toxin into a cigar, which I'm not sure maybe that's why Castro looks so young 'I'm not expecting side effects, 'but in rare cases, 'skin reactions and breathing difficulties have followed the use of Type-A toxin.
' Good So the ones around the eyes are a little bit sharper.
OK? I love a little bit sharper.
It's a euphemism, isn't it? We do normally give some anaesthetic cream for this sort of area.
I'm a big, strong boy trying not to scream.
Exactly.
'Actually, my main worry at this moment 'is if he overdoes it, then my eyes could get really droopy.
' That's it.
Wasn't painful, was it?No, no! THEY LAUGH Good.
Well, that was interesting.
Slightly more painful than I was expecting.
My skin is feeling a little bit sort of nibbled, but if the results are spectacular, then maybe it will be worth it.
A couple of weeks later, and I'm about to find out.
Well, my forehead is definitely much smoother.
As for the fine wrinkles around my eyes well, they've gone too, sort of.
So from that point of view, Botox definitely does what it says on the tin.
I asked my wife what she thought and she said I looked different, but I don't necessarily look any better.
None of my friends, until I point out to them, have commented on my new, enhanced looks.
So all in all, a really interesting experiment, but not one I think I'm going to repeat.
Botox is now part of an industry that is becoming ever more acceptable.
But 100 years ago, surgeons who attempted cosmetic surgery were viewed with suspicion.
It was known as beauty surgery and its practitioners were held with some contempt.
Even those who did major reconstructive work on people who were seriously injured were regarded not as real surgeons.
All that, however, was about to change.
WWI delivered slaughter on an epic scale.
A million British and Commonwealth soldiers died, but two million came home injured.
The men who fought in the trenches suffered horrific injuries, from gas attacks, from gunshot wounds, but most of all from this stuff - shrapnel.
When you stuck your head above the trenches, then a blast of shrapnel could rip your face off.
Surgeon Harold Gillies was 36 when war broke out.
Posted to France in 1914, he knew little of plastic surgery.
As a junior Red Cross officer, he was horrified by ghostly images of disfigured men limping back from the front.
He was also shocked to discover that French surgeons were way ahead of the British.
He immediately saw the opportunity to make himself the greatest plastic surgeon in the world.
By 1915, Gillies had his own plastics unit and two years later his own purpose-built hospital - the Queens in Sidcup.
It had 1,000 beds and was the first of its kind in the world.
The young Gillies was more magpie than innovator.
Obsessively poring through textbooks and research papers, he taught himself everything there was to know about reconstructive surgery.
Remarkably he got his patients by sending address labels marked "Sidcup Hospital" to the battlefields of the Western Front.
One soldier who turned up at Sidcup was Lieutenant William Spreckley.
This is William when he's just come in to the hospital.
His nose has been blown away and first reactions are really horror, revulsion, pity Gillies' solution was to use a new take on an old idea the Indian pedicle or forehead flap.
What Gillies decides to do is he removes a rib cartilage from William and moves it up and puts it in his forehead.
And there is this astonishing photograph here where you can see clearly the rib cartilage just beneath the skin.
He had to wander round looking like this for six months untill Gillies was able to swing the pedicle down and start repairing the nose.
Having swung the pedicle down, he could begin reconstructing the nose using Spreckley's forehead skin and the rib cartilage.
At this point, he frankly still looked utterly terrible.
Gillies himself described it as an anteater nose it is swollen, it is grotesque There's a look of terrible sadness in his eyes.
And then you come to the end, and this really is impressive because this is William when he's discharged and he still doesn't look happy, he still looks sad, he's obviously conscious of his looks.
But he is utterly transformed from the man who came in.
Encouraged, Gillies was keen to push the boundaries even further.
23-year-old Henry Lumley joined the fledgling Royal Flying Corps in December 1915.
It took him six months to qualify as a pilot.
And then tragically, on the day of his graduationhe crashed.
Lumley suffered horrific injuries.
Injuries which were impossible to repair using skin from anywhere on his face.
Gillies' reaction was nothing if not ambitious.
He decided to harvest a section of skin from Lumley's chest and use it to make him a new face.
It was a meticulously planned operation.
A large face-shaped flap of skin was lifted from his chest, still connected to his shoulders by pedicles that allowed blood to flow to the graft.
Things began well, but within days, the graft became infected.
Unable to bear the trauma of surgery Henry Lumley died of heart failure.
Gillies knew he had gone too far.
My desire to obtain a perfect result somewhat overrode my surgical judgement.
Never do today what can honorably be put off till tomorrow.
Gillies went back to his books.
But the urge to experiment did not leave him Like his predecessors, Gillies knew that excised strips of flesh needed to remain connected by means of a pedicle before they grew into their new home.
But as Lumley's case had proved, exposed flesh was dangerously prone to infection - infection which could kill.
By chance, Gillies then stumbled on an obscure Russian idea.
Simply wrap up all the skin and tissue into a tube.
It was called the tube pedicle.
It may look like a suitcase handle, but I think the tube pedicle was a stroke of surgical genius.
What's really clever about forming a tube is you get round the problem of infection because what you're doing is all the living tissue and blood supply is enclosed within the outer dead layer of skin, which is sort of waterproof and infection resistant.
So you could keep it in place for weeks at a time without a serious risk of it going horribly wrong.
The tube pedicle became Gillies' signature operation.
And though the original idea may have been borrowed from the Russians, Gillies was to make it his own with a brilliant piece of surgical improvisation.
He called this the Waltzing Tube pedicle.
If, for example, your chest was really burnt so you couldn't get the skin and tissue from there, he might collect it from your abdomen or even your leg.
He would then swing up this great, big mass of tube flesh and attach it to, say, the arm and then onto the face from there.
Fantastic.
The waltzing tube pedicle was Gillies' gift to reconstructive surgery.
A gift that would change the lives of servicemen not just in the First World War, but also the Second.
In 1940, the man who would pick up and develop Gillies' work was his cousin Archibald MacIndoe.
MacIndoe was a charismatic and brilliant surgeon who attributed his success to the presence of God coming down his right arm.
MacIndoe faced huge challenges.
Allied bomber crews were coming back from sorties with aviation fuel burns that had rarely been seen before.
19-year-old Bill Foxley was one such victim.
I was the navigator in a Wellington bomber and on March 16, 1944 and at 11.
20 at night we were taking off and, er something went wrong with the equipment and we dived straight into the ground from about 300 feet And it burst into flames, and, er I got myself out through the astrodome on the aircraft.
And I heard my wireless operator calling for help, and I climbed back in and helped to get him out.
And that's where a lot of the problems with my hands were came.
They were badly burned getting out, getting over hot metal.
But you just do these things without any thought.
If you stayed to think about it you probably wouldn't do it.
Burning aviation fuel was utterly merciless.
It vapourised Bill's's skin, causing damage that could only be repaired by a waltzing tube pedicle.
After three weeks, they detached one end and put it up onto your shoulder so that you had the tube there hanging like a trunk.
And then after another three weeks it was detached from the shoulder and put on the side of the face still forming the trunk.
Then another three weeks, was the final operation when the nose was formed and in my case the upper lip and I say that was over a period of three, six, nine weeks.
I remember when I had mine from my nose to my shoulder going outside the Canadian wing playing football Can you imagine it? You couldn't pull your head that way at all.
As I say, we did all sorts of mad things.
MacIndoe's genius was recognition of the importance of psychology in reconstructive surgery.
Archie MacIndoe was a great psychologist, as well as being a great surgeon, and he made sure that the first thing we did was to get out and about and in the public eye, and where better than to go than into the local pubs, and in fact, we used to go to London with these tubes on - frightened the life out of people - but that was all part of the game.
After WWI, Gillies' patients had struggled to find a place in Civvy Street.
Tortured by their looks, many took dead-end jobs working alone.
Suicides were not uncommon.
MacIndoe, though, had other ideas.
# We are MacIndoe's Army # We are his guinea pigs # With pedicles Glass eyes, false teeth, and wigs Bill Foxley and his fellow veterans wear their scars with pride.
Collectively known as the Guinea Pig Club, their mentor's approach to surgery not only healed their injuries, but also their minds.
And something else had been healed.
Plastic surgery, in 1914 a tarnished and disreputable business, had been transformed into the work of heroes.
Harold Gillies got a knighthood.
He'd worked as a government consultant during WWII.
But in 1945 he decided to use his reputation and celebrity status to embrace a new world.
The world of cosmetic surgery.
In this house, which is just off Harley Street, he went private, and he was soon earning the equivalent of ã1.
3m a year off the fading beauties of Mayfair and Knightsbridge.
Gillies, seen here operating in the 1940s, could have been collecting his old-age pension, But instead he used everything he'd learned from reconstructive surgery to embrace the new world of nip and tuck.
Like all great showmen, he left his best till last.
A procedure that would make headlines around the world.
In 1946 when he was almost 70, he decided to do an incredibly controversial operation.
The world's first female-to-male sex change.
The patient was a 31-year-old woman called Laura Dillon.
Having made his reputation with the tube pedicle, Gillies decided to use it for an altogether different purpose.
To create Laura's penis.
First the flesh was taken from her side Then it was filled with cartilage to give it mass.
And finally a rubber tube was connected to the urethra, which allowed normal urination.
With the help of the tube pedicle, Laura Dillon became Michael Dillon.
And he was obviously grateful because he later wrote - "To Sir Harold Gillies, I owe my life and happiness.
" In the post-war years, the legacy of men like Gillies and McIndoe helped plastic surgery reach new levels of sophistication.
But it was still by no means a perfect science.
They faced a fundamental problem.
If you want to move tissue around the body, you've got to keep it attached to a blood supply.
That meant lots of operations.
It also meant they were very limited in what they could do.
It was a problem first identified in India 3,000 years ago.
It was the reason Tagliocozzi employed bizarre methods in Renaissance Italy.
Methods which continued right up until the 1970s when surgeons finally found a solution.
Cancer patient Leslie Whiting is worried about her face.
It's not really been the same since she had part of her lower jaw and some teeth removed.
My confidence has been pretty much shattered.
I tend to hide away a lot now - I used to be a bubbly person but now I'm very aware of the way I look.
It really and truly is it's a strain to try and behave as normal as possible knowing that I don't look normal any more.
Today, surgeon Ian Hutchinson hopes to restore Leslie's jaw and her confidence.
He's going to rebuild her missing jaw bone by moving tissue and bone from her shoulder.
I'll be taking out the skin you can see here, some of the muscle around the bone, the bone itself, and the blood vessels that pump blood into it.
But he's not going to use a pedicle.
He's going to cut it off completely, with no blood supply whatsoever.
And this is why.
I need the microscope in.
Developed over 30 years ago, the operating microscope allowed surgeons, for the first time, to connect minute blood vessels together.
Banishing the need for pedicles.
Up to WWII, and Gillies and MacIndoe, they hadn't got a concept of a single blood vessel pumping blood into a flap and a single vein draining blood out of a flap.
But probably in the '70s we started to find that single artery could supply a whole swathe of tissue.
The operating microscope, together with advances in vascular surgery, helped solve a 2,500-year-old problem Light on, please.
Zoom, please.
Can I take my glasses off? Using the microscope, the severed artery from the transplanted tissue can be joined to Leslie's neck.
We'd like the blood supply to be joined up within 2ý to 3 hours.
It's a technique which has revolutionised the way reconstructive surgeons work.
Treatment is now simpler, faster, and there's less chance of failure.
Can I have a big wash, please? But is it really that hard? With Ian's help, I went to work.
It looks suspiciously like chicken legs It is exactly chicken legs.
And it's a way of training our juniors in microsurgery.
I've done suturing before but not like this - the blood vessels I'm trying to join are barely 2mm in diameter.
Ooh, trying to get perspective isthe depth I keep on trying to grab that bit and I It's very elusive.
Try and get the needle.
That's it, now you're in a perfect positionAh.
The magnification makes it feel like my hands belong to someone else.
Well done! Look at that! Anything other than a perfect join will cause blood to haemorrhage, which means I'll have failed.
This is unbelievably difficult.
You can breathe when you're doing it.
I can breathe! You don't have to stop breathing.
Got to calm down and breathe a bit more.
When Chinese surgeons first attempted microsurgery in the 1960s, they improvised with a pair of nylon stockings.
When unpicked, these delivered the finest thread on the planet.
Breathe in, now.
No, don't try and put it Oh, you've confounded me Well done! Oh, dear! OK, now pull through.
That's it.
Now you're on a roll.
Look at that.
Finally I'd done it.
Albeit just one stitch.
That is my first stitch.
It's absolutely fabulous.
I thought I wasn't gonna be able to do it.
That's a beautiful stitch! Thank you very much.
It's all operating in a completely different world, because it's down the microscope, it's very different.
Ithink it's just absolutely marvellous.
It really has been That really was a memorable moment in my life.
Using the operating microscope, Ian Hutchinson can now easily move tissue around a patient's body.
But our sensitivity to facial disfigurement means that surgeons aren't stopping here.
Can I get? Peter Butler is one of Britain's leading plastic surgeons.
He believes repairing the face with tissue from other parts of the body can sometimes be unsatisfactory.
The problem with moving pieces of tissue from other parts of the body is that it looks like where it's come from.
And not where it's going.
And that's one of the limitations.
Especially when all of the face is being reconstructed.
We run into this big problem that the tissue from the thigh or back or abdomen doesn't match that of the face.
The skin of the face is so specialised, actually, it's really nearly impossible to reconstruct it very well using these techniques.
The story of Jacqueline Saburido may well prove Peter's point.
In September 1999, Jacqui had just left a party when she was hit by a drunk driver.
Trapped in the car, Jacqui suffered burns to over 60% of her body.
But though two of her friends died, she survived.
50 operations later, this is how she looks.
Oh, that was more extreme than I was expecting.
When I look at that, it makes me feel incredibly uncomfortable.
Yeah, I look at it in a very different way.
I'm looking at a patient like this and saying OK, what could I improve? This is the end point of modern reconstructive surgery.
That's the best it gets?Yes.
She's had 40-50 operations on her face alone, and 20 on her left eye.
So that's as far as you can get with modern reconstructive processes.
When she talks about her normal day to day, he stays indoors, really, when she walks down the street, people scream and react badly, and that's unfortunately a common story for anyone with a severe facial injury.
They don't blend in, and that's actually what most want - to be normal.
Having treated people like Jackie, Peter Butler believes there may be a better way.
His solution is an operation that so far, has never been done.
He's now ready to perform the world's first full face transplant.
The idea isn't new.
In 2006, a French team successfully performed a partial transplant on 26-year-old Isabelle Dinoire - a woman who had been severely mauled by a dog.
TRANSLATION: Since the operation, I have a face like everyone else - I now have a second chance.
Even though the transplant was only partial, it was a huge leap forward.
So what did Isabelle show you? Well, Isabelle as you know was missing her nose, upper lip, lower lip and chin and the advantage of the transplant was she had replaced what she was missing, which was a real human nose, lips and chin And that's why it looks so good.
Absolutely.
it looks so normal.
There have been objections.
Some are worried about the person who donates their face.
Is it right to take their identity, after their death, and give it to someone else? And what about the donor family? Might they walk down the street one day, and see the face of a long-lost loved one? The implications for both patient and donor family are so profound, that Peter's team have simulated the reality of a face swap.
It's like a normal photograph.
You see a flash.
I'm having my photo taken.
This is no ordinary camera.
Eight different images are produced which are then fed into a computer.
One, two, three The information is then processed to produce a highly detailed 3D map of my face, as well as the muscle and bone structure beneath.
Going over where the flash hit the surface of your face It produces a 3D reconstruction.
That's the image with the texture on.
It's impressive.
Using this technique, I can now see what I would look like if I had Peter's dead face transplanted on my living one.
Good Lord, so this is basically your face on my bone structure.
Yes, as you can see, there's my eyebrows.
My skin pigmentation, you can see your structure.
If you came down the street, nobody would know.
They wouldn't recognise it on me.
It's not identifiable as me, it's more you than me.
How amazing.
How incredibly striking.
So in that sense, it is neither of us and it is more clearly you.
The donor family would be more comfortable.
Can I see it the other way round? If it was my dead face on your living Blimey! So this is You on me.
Your lashes, your lip You would never recognise it.
It looks more like me.
But I look at it and go, ooh The nose is yours as we would transplant that at the same time but my wife would recognise that as me.
Yes, absolutely.
Now, that was really interesting.
Clearly after a face transplant, you're not gonna look like yourself.
But nor are you going to look like anybody else.
Now, face transplants still face significant problems.
Not least the problems of immuno-suppression.
The drugs that need to be taken - they'll take about ten years off your life.
Now, I started off thinking this was probably not a good idea but if I were badly scarred then I think that ten years would be an acceptable risk.
A new face in exchange for ten years of your life.
It's a compromise.
But that's nothing new to plastic surgery.
Throughout history, every advance seems to have come with a price.
The scarring of the forehead after the Indian nasal reconstruction.
The brutality of Tagliocozzi's medieval treatment regime.
The failure of new cosmetic procedures.
And the limitations of even the most heroic surgical transformations, which emerged from two World Wars.
Peter Butler's confident that a full face transplant will go ahead.
He also believes that the operation may be obsolete in ten years.
By then, advances in tissue engineering, like those which allowed surgeons to grow a human ear on the back of a mouse, could make it possible to grow an entire new face from samples of the patient's own DNA.
If this happens, at a stroke it would remove the problem of rejection.
But who knows what unseen trade-offs that will involve? Coming up, I'm going back to surgery's crude beginnings Oh, GOD, that's HORRIBLE.
.
.
when it was little more than optimistic butchery.
That's it.
Hold him down! I reveal the fundamental breakthroughs that changed everything.
And show you how surgery was transformed into a discipline that for the very first time would cure more people than it killed.
In 2006, Isabelle Dinoire had a partial face transplant.
What separates these two women .
.
is 100 years of developments in plastic surgery.
Can I have the knife? My name is Michael Mosley, and when I was a young medical student, what I really wanted to be was a plastic surgeon.
That's because what surgeons can do, particularly with badly damaged faces is both awe inspiring and heart rending.
You had the tube there hanging like a trunk It's a 2,500-year journey.
From the earliest surgery, to 20th-century pioneers.
THEY SING In this programme, I'm going to lead you down the long, dark road that surgeons stumble along to take us to where we are today.
That's me on you.
Agh! Good Lord! How much does the look of a human face really matter to us? Using this brain scanner, I'm about to find out.
By allowing it to read my mind.
We're just about ready to get started here.
Everything OK with you?Yep, fine.
As I lie locked inside the core of an electro-magnet, a series of faces are projected onto a screen.
At first, they're ordinary, normal faces.
But then they become disturbing, damaged.
There are some pretty horrific images in there.
Difficult, aren't they?Oh I mean Yes! I try to control my feelings, but the brain scan is going to reveal my true reactions.
OK, so that's the end.
I'll just come in and get you out, OK? Oh! Oh, that really was quite quite disturbing.
I'll be very interested to see what the reaction of my brain is, because as I was lying looking at some of those faces, I thought, "Oh, dear.
Oh, dear.
Oh, dear.
" OK, this is essentially my lovely brain here? That's right.
That's it there.
Very nice looking brain.
This is a snapshot taken during the experiment.
The green spot shows unusual activity in the amygdala, a primitive part of the brain that processes fear and disgust.
The amygdala is associated with a lot of the negative responses.
Right.
If we look at the response, this is how much stronger your response was to those disfigured faces than the normal faces.
The normal face response was no different from base line.
Right, so basically, this is insignificant and that's big?Yes.
So essentially, what's happening here is I'm having a big negative, possibly disgust response to the faces I'm looking at.
Right.
But this would be pretty much a normal human reaction to a distorted face.
You seem like a normal human being! Thank you very much.
Sometimes, I wonder! But it is very, very striking.
They were disturbing, but I was trying to feel compassionate.
But generally, it looks like my reaction was negative.
Yeah.
I was strongly emotionally negative.
Right, exactly.
Which is a shame, cos I like to think of myself as a compassionate guy, but it seems to be Well, like I said, I suspect you felt compassion.
You also felt that negative, natural response that people feel to these sorts of faces.
I'm slightly ashamed, cos I sort of thought I would be able to control my emotions more.
But it didn't happen like that.
No.
How fascinating.
Really interesting, thank you.
That was really interesting.
When you see just how profoundly the brain responds to disfigured faces, you can understand - if you looked like that - how much you might want to change.
Our unfortunate reaction to disfigurement seems to be deeply engrained, and it's certainly not new.
Attempts to surgically alter how people look have been going on for millennia.
The Hindu poem Ramayana was written about 3,500 years ago.
It tells the story of Surpanaka, a temptress found guilty of infidelity.
Her punishment was brutal.
She lost her nose.
The practice of cutting off a nose as a form of punishment went on in India well into the 20th century.
But what really interests me about this particular poem is what happened next.
Our seductress, having had her nose chopped off, immediately went for reconstructive surgery.
The poem doesn't say how it was done, but there's a clue in an Indian medical text written in 600BC.
The technique described was clever, and it featured a fundamental principle of reconstructive surgery that would be used right up to the 20th Century.
Clever, but not pain free.
2,500 years before the discovery of anaesthetics, the operation would start with a knife to the forehead.
As I'm demonstrating with this very realistic model.
It's a searing 5mm cut down to the periosteum.
A membrane which covers the skull.
Right.
Well, I've got there, now I've got to tweak it up.
I cannot imagine what it would have been like to do this on a living, breathing, screaming human being.
I've now reached a critical stage.
What I really don't want to do is break off this.
This is what the Indians called a pedicle, because if I just took a piece of tissue here and just cut the whole thing off and stuck it on the nose, this would die, because the area here is rich in blood vessels, and what you want to do is try and preserve them.
What I'm going to do, I think you can see now, is lift it up.
Give it a little bit of a twist.
And I think you can see the formation of a new nose.
Isn't that wonderful? This pedicle has still got a good blood supply.
And that will bring life to this nose.
The Indians knew nothing about the circulatory system, but they did realise that without an adequate blood supply, any tissue they mobilised to create a new nose would swiftly die.
When you think that they were doing this 2,600 years ago, I think that is quite remarkable.
This, this is the beginning of reconstructive surgery.
Surpanaka got her new nose, but it would have been at the expense of bearing a hideous scar on her forehead.
It was a problem that wouldn't be addressed for over 2,000 years.
Fast forward to Renaissance Italy and Bologna .
.
home to a surgical pioneer who would try a rather different approach to nasal reconstruction.
In 16th-century Bologna, there was not only an explosion of art and science, but disease.
Syphilis, a hideous sickness that is thought to have been imported from South America.
It turned its victims into social pariahs.
Identified as moral degenerates by their lack of a nose.
But here at the University of Bologna medical school, a radical new treatment was about to emerge.
The man who inspired it was Gaspare Tagliacozzi.
His declared mission was to bring back, re-fashion and restore to wholeness the features which nature gave, but chance destroyed.
Tagliacozzi experimented with all kinds of facial reconstructive surgery, but in particular, noses.
His method for repairing nasal collapse was based on work originally done in Sicily, and it was inspired.
Plastic surgeon Paolo Santoni-Rugiu has studied how he did it.
They made two parallel incisions.
Blimey, did that hurt?No Yes! It was very quick, just like this.
Just like that.
Then he undermined the skin so it was loose.
Right.
So he had something like this.
That was the pedicle.
After two or three weeks, it attached to the nose.
Oh, right.
How?Like this.
Cor.
Very complicated.
Very complicated and not very comfortable.
The blood supply was coming from the lower pedicle.
And also through the scar that was produced on the nose.
Right, so he's got to wait for the blood supply to re-grow in the nose bit before he can cut off the arm bit?Yes.
'Before your new nose could be reconstructed, 'you had to hold your arm like this for at least two weeks.
'Fortunately, Tagliacozzi had an answer' A surgical straight jacket.
His design is lovingly detailed in this 16th-century illustration.
And I'm about to try one on.
This jacket was essential for a successful surgical outcome.
The transplanted skin flap had to remain attached to the arm until new blood vessels had time to grow from the stump of the nose and into the skin.
And that meant waiting.
And waiting.
After a week or more of bed rest, patients were allowed to get up and move around.
It's difficult to actually see if people are staring, cos I've got a limited view underneath my arm pit.
It is uncomfortable and embarrassing.
And it speaks volumes about the stigma of syphilis that anyone thought this was worth going through.
And the jacket was only part of his bizarre treatment plan.
Tagliacozzi was extremely interested in nutrition.
In fact, he recommended patients - both before and after this particular operation - totally abstained from eating fish.
If they must eat meat, it should be roasted and not boiled.
Two hours in, and I'm starting to feel the strain.
Ooh It's really quite uncomfortable, I must admit.
Ooh Even more uncomfortable than I thought it was gonna be.
Aah The bit which really gets me is in the neck here, because what's happening is the whole weight of my forearm is resting on this, which is driving my head remorselessly forward.
Very, very uncomfortable.
I've had it on for a short period of time, but I can already feel my neck going.
I think I have had enough.
I'm cold, my neck really aches Trying to get this out.
Oh, God that's better! I only had to wear it for a relatively short period of time.
I just cannot imagine keeping this on for a couple of weeks, let alone any longer.
The straight jacket may be off, but my imagined nasal reconstruction has hardly begun.
To find out what happened next, I've come to Bologna's magnificent biblioteca scientifica.
In here, there is a copy of Tagliacozzi's 1597 masterpiece.
The first ever book on reconstructive surgery.
And it clearly shows the next stage of the Italian nose job.
Well Here, you can see There is the operation where the flap is attached to the nose.
And you can recognise the awful position.
So after two or three weeks, you separate the flap and the nose from the arm.
And you remove this apparatus.
And you will have this piece of skin hanging from the nose.
And you leave this flap hanging.
It's not very attractive looking.
It's not very attractive nose.
Once you start remodelling, it is done mainly with splints, and this lasted at least two months.
Does he have a final picture showing the happy patient at the end? Oh, yes.
Hurrah! You can see the scar.
And a very pretty nose.
And the nose is pretty, yeah.
It certainly shows the power, doesn't it, of a picture? Because if I was a patient and the doctor came and showed me that, I would go, "Yes, please.
" But the reality was probably not as spectacularly good as that.
But it certainly had a big impression, this book.
Oh, yeah, it's still today, or certainly, it was for sure until 25 years ago, the main method of repair to transfer skin from one part of the body to another.
The start of modern plastic surgery is this.
But Tagliacozzi's fame was short lived.
When he died two years later, his reputation collapsed.
The Italian church summoned its religious investigators, the tribunal of the inquisition.
Because Tagliacozzi had modified the human face, he was accused of interfering with God's will.
Although posthumously exonerated .
.
stories persist that his bones were dug up and dumped on unconsecrated ground.
For the next 200 years, his successors experimented with a variety of reconstructive techniques.
From tie-on noses .
.
to attempts at rebuilding hair lips.
Until the 19th century, almost all facial surgery was reconstructive surgery.
The repair of damaged and diseased faces.
But in the mid-19th century, something new occurs.
Cosmetic surgery.
The attempts to take perfectly normal people and make them more beautiful.
Aaaagh! The discovery of anaesthetics in the 1840s was a huge factor.
Now, if you wanted to look better or younger, you could be almost sure that it wouldn't hurt too much.
With the discovery of anaesthetics, and also cleaner operating theatres which meant there was less risk of infection, facial surgery really became fashionable again.
But this time, instead of using skin and flesh, they tried inserting a range of other strange substances.
Ivory.
Gutta-percha, which is actually the sap from a tree.
And if you warm it up, it becomes soft, and you can use it in the nose.
And this, which I think is really disgusting, it's animal cartilage.
They would use this to try and repair the nose.
One surgeon was so desperate, he actually brought a duck into the operating theatre, slit its throat, removed the breast bone and tried using that to repair his patient's nose.
It failed, of course.
Despite repeated failures, demand for cosmetic procedures at the end of the 19th century absolutely soared.
The surgeons' materials may have been risible, but one in particular became notorious.
And this is it - paraffin wax.
One of the great inventions of the late 19th century.
At room temperature, it's a solid.
But when you heat it up, it goes into a liquid.
And in the liquid form, they would inject it into your face, your buttocks, even into your penis.
It was superb stuff, because as it cooled down, the surgeons could really manipulate and shape it.
What could possibly go wrong? In 1903, society beauty Gladys Deacon heard about the new craze.
Gladys would go onto marry the Duke of Marlborough and install herself in Blenheim Palace.
But the thing she's now really famous for is what she did to her nose.
A nose she hated.
Gladys obsessively toured round galleries, looking at faces, eyes, lips, but particularly noses.
In Edwardian England, neo-classicism was all the rage.
And it was amongst the contours of Classical sculpture that Gladys discovered THE perfect nose.
A nose she decided to have sculpted with paraffin wax.
Now, even the British Medical Journal had enthused about the new wonder treatment .
.
detailing its use on the bridge of the nose as "simplicity itself "with an immediate and excellent result.
" A result which left no scar and avoided the need for invasive surgery.
Gladys was sold.
But the procedure was not exactly pain-free.
Well, not for the patient anyway.
The doctor would have worn protective gloves when holding the syringe, as it was heated way beyond the melting point of wax to prevent hardening inside the chamber.
After nicking the entry point with a scalpel .
.
hot wax was delivered straight into the nose.
Once inside, there was 30 seconds before it hardened.
30 seconds to mould the perfect nose.
But perfection was not what Gladys got.
Soon after the injections, the wax began to wander.
Gladys' face was mutating.
Her looks were being destroyed.
And she was not alone.
Others had noticed that wax often hardened and clumped after being injected.
Sometimes leading to open sores.
People went blind.
Some got blood clots in the lungs.
Others, necrosis at the injection site.
The flesh just withered and died.
Gladys' condition was quickly labelled paraffinoma, though many called it wax cancer.
It's said she would later sit by the fire in Blenheim Palace letting the heat soften the paraffin beneath her skin, so she could move it around her face.
Still searching for the perfect nose.
You'd have thought that cases like that would have put people off.
But far from it.
Having failed with paraffin wax, people moved on to new materials.
Olive oil, Vaseline, glycerine boiled in carbolic acid, and later, the hugely disastrous industrial silicone.
It seems the pursuit of beauty through a needle was simply irresistible.
The most popular cosmetic procedure is still injections in the face.
But these days, they're not using anything as crude as paraffin wax.
No.
They're using instead a neurotoxin, which is derived from a particularly unpleasant form of food-poisoning bacteria.
Clostridium botulinum.
More commonly known as Botox.
Clostridium botulinum, from which the brand name Botox is derived, is one of the most poisonous substances known.
If evenly dispersed and inhaled, a single gram would kill more than a million people.
In the 1960s, a milder version, the so-called Type A toxin, was first used to treat people with facial ticks.
A cosmetic wonder drug had been born, albeit by accident, and I'm about to try it.
Dr Ross Perry is going to make me a member of the Botox generation.
It's very curious, isn't it? The idea of using something which I read is apparently, the mostpoisonous substance in the known universe, or whatever.
It's, erm The doses that we're using are extremely small to get the sort of reactions that you are sort of talking about.
Tens of thousands higher than this, so Unlikely, even if I inhaled huge amounts of it, that it's going to do anything.
If you drank the bottle, you'd get a little bit of diarrhoea.
I don't think we're gonna do that! Do you do guys my age commonly, or not? Erm, guys your age would have already Most of my patients would have probably already have had some You're really groping for some sort of euphemism there, I can see.
Certainly, we do get patients of your age.
Erm However, we've got to, obviously, consult them with regard to what the perceived outcome is likely to be.
And what is the perceived outcome likely to be in my case?You will notice some benefit, but obviously, it's not going to be as beneficial as if you'd been five, ten years younger.
It's a bit late now, is it? My creases are set in their ways.
They're a little bit deeper.
Your skin is a little bit more lax, and as a result, we can't give you the same volume in the same areas without possibly causing a few side effects.
But worth giving it a go anyway.
In your case, I don't see any reason why not.
No.
Even the refined Type-A toxin is potentially dangerous.
Ross uses an almost undetectable quantity, which he then dilutes in saline.
It will be delivered to me in 23 separate injections.
OK.
Really, we're just injecting points In its natural deadly form, Clostridium botulinum kills by paralysing the muscles of the heart and lungs, and causing paralysis is exactly what the milder Type-A toxin should do.
Though hopefully, will only affect the small muscles in my face.
I read somewhere that the CIA tried to assassinate Castro, apparentlyReally? .
.
not I think, by giving him Botox, but by sticking the botulinum toxin into a cigar, which I'm not sure maybe that's why Castro looks so young 'I'm not expecting side effects, 'but in rare cases, 'skin reactions and breathing difficulties have followed the use of Type-A toxin.
' Good So the ones around the eyes are a little bit sharper.
OK? I love a little bit sharper.
It's a euphemism, isn't it? We do normally give some anaesthetic cream for this sort of area.
I'm a big, strong boy trying not to scream.
Exactly.
'Actually, my main worry at this moment 'is if he overdoes it, then my eyes could get really droopy.
' That's it.
Wasn't painful, was it?No, no! THEY LAUGH Good.
Well, that was interesting.
Slightly more painful than I was expecting.
My skin is feeling a little bit sort of nibbled, but if the results are spectacular, then maybe it will be worth it.
A couple of weeks later, and I'm about to find out.
Well, my forehead is definitely much smoother.
As for the fine wrinkles around my eyes well, they've gone too, sort of.
So from that point of view, Botox definitely does what it says on the tin.
I asked my wife what she thought and she said I looked different, but I don't necessarily look any better.
None of my friends, until I point out to them, have commented on my new, enhanced looks.
So all in all, a really interesting experiment, but not one I think I'm going to repeat.
Botox is now part of an industry that is becoming ever more acceptable.
But 100 years ago, surgeons who attempted cosmetic surgery were viewed with suspicion.
It was known as beauty surgery and its practitioners were held with some contempt.
Even those who did major reconstructive work on people who were seriously injured were regarded not as real surgeons.
All that, however, was about to change.
WWI delivered slaughter on an epic scale.
A million British and Commonwealth soldiers died, but two million came home injured.
The men who fought in the trenches suffered horrific injuries, from gas attacks, from gunshot wounds, but most of all from this stuff - shrapnel.
When you stuck your head above the trenches, then a blast of shrapnel could rip your face off.
Surgeon Harold Gillies was 36 when war broke out.
Posted to France in 1914, he knew little of plastic surgery.
As a junior Red Cross officer, he was horrified by ghostly images of disfigured men limping back from the front.
He was also shocked to discover that French surgeons were way ahead of the British.
He immediately saw the opportunity to make himself the greatest plastic surgeon in the world.
By 1915, Gillies had his own plastics unit and two years later his own purpose-built hospital - the Queens in Sidcup.
It had 1,000 beds and was the first of its kind in the world.
The young Gillies was more magpie than innovator.
Obsessively poring through textbooks and research papers, he taught himself everything there was to know about reconstructive surgery.
Remarkably he got his patients by sending address labels marked "Sidcup Hospital" to the battlefields of the Western Front.
One soldier who turned up at Sidcup was Lieutenant William Spreckley.
This is William when he's just come in to the hospital.
His nose has been blown away and first reactions are really horror, revulsion, pity Gillies' solution was to use a new take on an old idea the Indian pedicle or forehead flap.
What Gillies decides to do is he removes a rib cartilage from William and moves it up and puts it in his forehead.
And there is this astonishing photograph here where you can see clearly the rib cartilage just beneath the skin.
He had to wander round looking like this for six months untill Gillies was able to swing the pedicle down and start repairing the nose.
Having swung the pedicle down, he could begin reconstructing the nose using Spreckley's forehead skin and the rib cartilage.
At this point, he frankly still looked utterly terrible.
Gillies himself described it as an anteater nose it is swollen, it is grotesque There's a look of terrible sadness in his eyes.
And then you come to the end, and this really is impressive because this is William when he's discharged and he still doesn't look happy, he still looks sad, he's obviously conscious of his looks.
But he is utterly transformed from the man who came in.
Encouraged, Gillies was keen to push the boundaries even further.
23-year-old Henry Lumley joined the fledgling Royal Flying Corps in December 1915.
It took him six months to qualify as a pilot.
And then tragically, on the day of his graduationhe crashed.
Lumley suffered horrific injuries.
Injuries which were impossible to repair using skin from anywhere on his face.
Gillies' reaction was nothing if not ambitious.
He decided to harvest a section of skin from Lumley's chest and use it to make him a new face.
It was a meticulously planned operation.
A large face-shaped flap of skin was lifted from his chest, still connected to his shoulders by pedicles that allowed blood to flow to the graft.
Things began well, but within days, the graft became infected.
Unable to bear the trauma of surgery Henry Lumley died of heart failure.
Gillies knew he had gone too far.
My desire to obtain a perfect result somewhat overrode my surgical judgement.
Never do today what can honorably be put off till tomorrow.
Gillies went back to his books.
But the urge to experiment did not leave him Like his predecessors, Gillies knew that excised strips of flesh needed to remain connected by means of a pedicle before they grew into their new home.
But as Lumley's case had proved, exposed flesh was dangerously prone to infection - infection which could kill.
By chance, Gillies then stumbled on an obscure Russian idea.
Simply wrap up all the skin and tissue into a tube.
It was called the tube pedicle.
It may look like a suitcase handle, but I think the tube pedicle was a stroke of surgical genius.
What's really clever about forming a tube is you get round the problem of infection because what you're doing is all the living tissue and blood supply is enclosed within the outer dead layer of skin, which is sort of waterproof and infection resistant.
So you could keep it in place for weeks at a time without a serious risk of it going horribly wrong.
The tube pedicle became Gillies' signature operation.
And though the original idea may have been borrowed from the Russians, Gillies was to make it his own with a brilliant piece of surgical improvisation.
He called this the Waltzing Tube pedicle.
If, for example, your chest was really burnt so you couldn't get the skin and tissue from there, he might collect it from your abdomen or even your leg.
He would then swing up this great, big mass of tube flesh and attach it to, say, the arm and then onto the face from there.
Fantastic.
The waltzing tube pedicle was Gillies' gift to reconstructive surgery.
A gift that would change the lives of servicemen not just in the First World War, but also the Second.
In 1940, the man who would pick up and develop Gillies' work was his cousin Archibald MacIndoe.
MacIndoe was a charismatic and brilliant surgeon who attributed his success to the presence of God coming down his right arm.
MacIndoe faced huge challenges.
Allied bomber crews were coming back from sorties with aviation fuel burns that had rarely been seen before.
19-year-old Bill Foxley was one such victim.
I was the navigator in a Wellington bomber and on March 16, 1944 and at 11.
20 at night we were taking off and, er something went wrong with the equipment and we dived straight into the ground from about 300 feet And it burst into flames, and, er I got myself out through the astrodome on the aircraft.
And I heard my wireless operator calling for help, and I climbed back in and helped to get him out.
And that's where a lot of the problems with my hands were came.
They were badly burned getting out, getting over hot metal.
But you just do these things without any thought.
If you stayed to think about it you probably wouldn't do it.
Burning aviation fuel was utterly merciless.
It vapourised Bill's's skin, causing damage that could only be repaired by a waltzing tube pedicle.
After three weeks, they detached one end and put it up onto your shoulder so that you had the tube there hanging like a trunk.
And then after another three weeks it was detached from the shoulder and put on the side of the face still forming the trunk.
Then another three weeks, was the final operation when the nose was formed and in my case the upper lip and I say that was over a period of three, six, nine weeks.
I remember when I had mine from my nose to my shoulder going outside the Canadian wing playing football Can you imagine it? You couldn't pull your head that way at all.
As I say, we did all sorts of mad things.
MacIndoe's genius was recognition of the importance of psychology in reconstructive surgery.
Archie MacIndoe was a great psychologist, as well as being a great surgeon, and he made sure that the first thing we did was to get out and about and in the public eye, and where better than to go than into the local pubs, and in fact, we used to go to London with these tubes on - frightened the life out of people - but that was all part of the game.
After WWI, Gillies' patients had struggled to find a place in Civvy Street.
Tortured by their looks, many took dead-end jobs working alone.
Suicides were not uncommon.
MacIndoe, though, had other ideas.
# We are MacIndoe's Army # We are his guinea pigs # With pedicles Glass eyes, false teeth, and wigs Bill Foxley and his fellow veterans wear their scars with pride.
Collectively known as the Guinea Pig Club, their mentor's approach to surgery not only healed their injuries, but also their minds.
And something else had been healed.
Plastic surgery, in 1914 a tarnished and disreputable business, had been transformed into the work of heroes.
Harold Gillies got a knighthood.
He'd worked as a government consultant during WWII.
But in 1945 he decided to use his reputation and celebrity status to embrace a new world.
The world of cosmetic surgery.
In this house, which is just off Harley Street, he went private, and he was soon earning the equivalent of ã1.
3m a year off the fading beauties of Mayfair and Knightsbridge.
Gillies, seen here operating in the 1940s, could have been collecting his old-age pension, But instead he used everything he'd learned from reconstructive surgery to embrace the new world of nip and tuck.
Like all great showmen, he left his best till last.
A procedure that would make headlines around the world.
In 1946 when he was almost 70, he decided to do an incredibly controversial operation.
The world's first female-to-male sex change.
The patient was a 31-year-old woman called Laura Dillon.
Having made his reputation with the tube pedicle, Gillies decided to use it for an altogether different purpose.
To create Laura's penis.
First the flesh was taken from her side Then it was filled with cartilage to give it mass.
And finally a rubber tube was connected to the urethra, which allowed normal urination.
With the help of the tube pedicle, Laura Dillon became Michael Dillon.
And he was obviously grateful because he later wrote - "To Sir Harold Gillies, I owe my life and happiness.
" In the post-war years, the legacy of men like Gillies and McIndoe helped plastic surgery reach new levels of sophistication.
But it was still by no means a perfect science.
They faced a fundamental problem.
If you want to move tissue around the body, you've got to keep it attached to a blood supply.
That meant lots of operations.
It also meant they were very limited in what they could do.
It was a problem first identified in India 3,000 years ago.
It was the reason Tagliocozzi employed bizarre methods in Renaissance Italy.
Methods which continued right up until the 1970s when surgeons finally found a solution.
Cancer patient Leslie Whiting is worried about her face.
It's not really been the same since she had part of her lower jaw and some teeth removed.
My confidence has been pretty much shattered.
I tend to hide away a lot now - I used to be a bubbly person but now I'm very aware of the way I look.
It really and truly is it's a strain to try and behave as normal as possible knowing that I don't look normal any more.
Today, surgeon Ian Hutchinson hopes to restore Leslie's jaw and her confidence.
He's going to rebuild her missing jaw bone by moving tissue and bone from her shoulder.
I'll be taking out the skin you can see here, some of the muscle around the bone, the bone itself, and the blood vessels that pump blood into it.
But he's not going to use a pedicle.
He's going to cut it off completely, with no blood supply whatsoever.
And this is why.
I need the microscope in.
Developed over 30 years ago, the operating microscope allowed surgeons, for the first time, to connect minute blood vessels together.
Banishing the need for pedicles.
Up to WWII, and Gillies and MacIndoe, they hadn't got a concept of a single blood vessel pumping blood into a flap and a single vein draining blood out of a flap.
But probably in the '70s we started to find that single artery could supply a whole swathe of tissue.
The operating microscope, together with advances in vascular surgery, helped solve a 2,500-year-old problem Light on, please.
Zoom, please.
Can I take my glasses off? Using the microscope, the severed artery from the transplanted tissue can be joined to Leslie's neck.
We'd like the blood supply to be joined up within 2ý to 3 hours.
It's a technique which has revolutionised the way reconstructive surgeons work.
Treatment is now simpler, faster, and there's less chance of failure.
Can I have a big wash, please? But is it really that hard? With Ian's help, I went to work.
It looks suspiciously like chicken legs It is exactly chicken legs.
And it's a way of training our juniors in microsurgery.
I've done suturing before but not like this - the blood vessels I'm trying to join are barely 2mm in diameter.
Ooh, trying to get perspective isthe depth I keep on trying to grab that bit and I It's very elusive.
Try and get the needle.
That's it, now you're in a perfect positionAh.
The magnification makes it feel like my hands belong to someone else.
Well done! Look at that! Anything other than a perfect join will cause blood to haemorrhage, which means I'll have failed.
This is unbelievably difficult.
You can breathe when you're doing it.
I can breathe! You don't have to stop breathing.
Got to calm down and breathe a bit more.
When Chinese surgeons first attempted microsurgery in the 1960s, they improvised with a pair of nylon stockings.
When unpicked, these delivered the finest thread on the planet.
Breathe in, now.
No, don't try and put it Oh, you've confounded me Well done! Oh, dear! OK, now pull through.
That's it.
Now you're on a roll.
Look at that.
Finally I'd done it.
Albeit just one stitch.
That is my first stitch.
It's absolutely fabulous.
I thought I wasn't gonna be able to do it.
That's a beautiful stitch! Thank you very much.
It's all operating in a completely different world, because it's down the microscope, it's very different.
Ithink it's just absolutely marvellous.
It really has been That really was a memorable moment in my life.
Using the operating microscope, Ian Hutchinson can now easily move tissue around a patient's body.
But our sensitivity to facial disfigurement means that surgeons aren't stopping here.
Can I get? Peter Butler is one of Britain's leading plastic surgeons.
He believes repairing the face with tissue from other parts of the body can sometimes be unsatisfactory.
The problem with moving pieces of tissue from other parts of the body is that it looks like where it's come from.
And not where it's going.
And that's one of the limitations.
Especially when all of the face is being reconstructed.
We run into this big problem that the tissue from the thigh or back or abdomen doesn't match that of the face.
The skin of the face is so specialised, actually, it's really nearly impossible to reconstruct it very well using these techniques.
The story of Jacqueline Saburido may well prove Peter's point.
In September 1999, Jacqui had just left a party when she was hit by a drunk driver.
Trapped in the car, Jacqui suffered burns to over 60% of her body.
But though two of her friends died, she survived.
50 operations later, this is how she looks.
Oh, that was more extreme than I was expecting.
When I look at that, it makes me feel incredibly uncomfortable.
Yeah, I look at it in a very different way.
I'm looking at a patient like this and saying OK, what could I improve? This is the end point of modern reconstructive surgery.
That's the best it gets?Yes.
She's had 40-50 operations on her face alone, and 20 on her left eye.
So that's as far as you can get with modern reconstructive processes.
When she talks about her normal day to day, he stays indoors, really, when she walks down the street, people scream and react badly, and that's unfortunately a common story for anyone with a severe facial injury.
They don't blend in, and that's actually what most want - to be normal.
Having treated people like Jackie, Peter Butler believes there may be a better way.
His solution is an operation that so far, has never been done.
He's now ready to perform the world's first full face transplant.
The idea isn't new.
In 2006, a French team successfully performed a partial transplant on 26-year-old Isabelle Dinoire - a woman who had been severely mauled by a dog.
TRANSLATION: Since the operation, I have a face like everyone else - I now have a second chance.
Even though the transplant was only partial, it was a huge leap forward.
So what did Isabelle show you? Well, Isabelle as you know was missing her nose, upper lip, lower lip and chin and the advantage of the transplant was she had replaced what she was missing, which was a real human nose, lips and chin And that's why it looks so good.
Absolutely.
it looks so normal.
There have been objections.
Some are worried about the person who donates their face.
Is it right to take their identity, after their death, and give it to someone else? And what about the donor family? Might they walk down the street one day, and see the face of a long-lost loved one? The implications for both patient and donor family are so profound, that Peter's team have simulated the reality of a face swap.
It's like a normal photograph.
You see a flash.
I'm having my photo taken.
This is no ordinary camera.
Eight different images are produced which are then fed into a computer.
One, two, three The information is then processed to produce a highly detailed 3D map of my face, as well as the muscle and bone structure beneath.
Going over where the flash hit the surface of your face It produces a 3D reconstruction.
That's the image with the texture on.
It's impressive.
Using this technique, I can now see what I would look like if I had Peter's dead face transplanted on my living one.
Good Lord, so this is basically your face on my bone structure.
Yes, as you can see, there's my eyebrows.
My skin pigmentation, you can see your structure.
If you came down the street, nobody would know.
They wouldn't recognise it on me.
It's not identifiable as me, it's more you than me.
How amazing.
How incredibly striking.
So in that sense, it is neither of us and it is more clearly you.
The donor family would be more comfortable.
Can I see it the other way round? If it was my dead face on your living Blimey! So this is You on me.
Your lashes, your lip You would never recognise it.
It looks more like me.
But I look at it and go, ooh The nose is yours as we would transplant that at the same time but my wife would recognise that as me.
Yes, absolutely.
Now, that was really interesting.
Clearly after a face transplant, you're not gonna look like yourself.
But nor are you going to look like anybody else.
Now, face transplants still face significant problems.
Not least the problems of immuno-suppression.
The drugs that need to be taken - they'll take about ten years off your life.
Now, I started off thinking this was probably not a good idea but if I were badly scarred then I think that ten years would be an acceptable risk.
A new face in exchange for ten years of your life.
It's a compromise.
But that's nothing new to plastic surgery.
Throughout history, every advance seems to have come with a price.
The scarring of the forehead after the Indian nasal reconstruction.
The brutality of Tagliocozzi's medieval treatment regime.
The failure of new cosmetic procedures.
And the limitations of even the most heroic surgical transformations, which emerged from two World Wars.
Peter Butler's confident that a full face transplant will go ahead.
He also believes that the operation may be obsolete in ten years.
By then, advances in tissue engineering, like those which allowed surgeons to grow a human ear on the back of a mouse, could make it possible to grow an entire new face from samples of the patient's own DNA.
If this happens, at a stroke it would remove the problem of rejection.
But who knows what unseen trade-offs that will involve? Coming up, I'm going back to surgery's crude beginnings Oh, GOD, that's HORRIBLE.
.
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when it was little more than optimistic butchery.
That's it.
Hold him down! I reveal the fundamental breakthroughs that changed everything.
And show you how surgery was transformed into a discipline that for the very first time would cure more people than it killed.