Blood and Guts: A History of Surgery

CHAPTER 4. FACES

THE ITALIAN NOSE JOB

Bologna, Italy, 1597


Bologna was fast becoming the syphilis capital of Europe. This wasn't something anyone advertised or put on the signs. It wasn't good for business – particularly if your business was prostitution – but the ravages of the disease were clear for all to see. Syphilis was debilitating, disfiguring and, in most people's opinion, downright disgusting.

An unwelcome import into Italy from South America, syphilis is caused by tiny coiled bacteria. The disease is spread through contact and, as it needs moisture to survive, the contact is often of a sexual nature. Without treatment, syphilis spreads rapidly through the body. It starts with swelling around the site of the infection, but within weeks the victims develop rashes, fevers and headaches. They will suffer painful lesions in the mouth, throat and anus. As the disease progresses, the body becomes covered with ulcers and tumours, and clumps of hair fall from the head.

Worse is to come.

While the patient becomes increasingly disfigured on the outside, the bacteria are conducting a hidden campaign of destruction inside the body. They attack bones and muscles, covering them with rubbery tumours that affect posture and movement. If the victim has somehow managed to conceal the effects of the disease up to this point, syphilis then launches a final nasty surprise. As these tumours spread, they begin to erode the bones of the nose. When the nose collapses, the victims are left deformed, their face distorted, their appearance repulsive.

Doctors had all sorts of treatment on offer for syphilis. These invariably involved bloodletting or expensive concoctions of herbs and unlikely bits of animals. Nothing was effective. Within a matter of weeks, the victim went from upright citizen to social pariah, with a caved-in face to match. Sufferers were shunned as moral degenerates. They would do anything to have their faces restored. Here was the perfect market opportunity for any enterprising surgeon.

Gaspare Tagliacozzi was undoubtedly one of Italy's greatest surgeons, renowned as a brilliant practitioner. He had risen rapidly through the ranks of the University of Bologna Medical School – Italy's foremost medical university. By the age of thirtyfive he had been honoured with civil office, and had even been granted the privilege of conducting public demonstrations of anatomy. As his reputation spread, Tagliacozzi's rich, famous and, importantly, influential clients came to include the very finest of Italian nobility.

One of his earliest patients was the distinguished Count Paolo Emilio Boschetti of Modena. The count had suffered a broken arm that had healed badly. He came to Tagliacozzi seeking treatment for the stiffness.

The surgeon examined the limb and diagnosed that there was a problem with the 'materials within'. So that movement could be restored, the tendons and ligaments needed to be softened. Tagliacozzi had been schooled well and knew just what was needed. He prescribed that the arm should be held in the warm entrails of a sheep for an hour a day. Afterwards the arm was to be placed in a hot bath of herbs for half an hour. Finally, it should be washed with warm wine before being dried. It was important that the patient had not previously eaten anything, so perhaps the count might consider undertaking his treatment before breakfast? Although whether he would feel like having breakfast after dousing his arm in bits of dead sheep is debatable.

Tagliacozzi's treatments were in the finest traditions of the self-appointed father of surgery, Claudius Galen (see Chapter 1). Despite their dubious efficacy, they were well received by patients, and Tagliacozzi soon had a thriving business, in addition to his salary from the university. But while private clients made him wealthy, it was his anatomical demonstrations that drew the crowds and helped make his name as a surgeon. He had a reputation as a fine teacher and commanded great loyalty among his students.

Anatomical dissections were undertaken only by senior members of the faculty. They were such rare events that the lecture theatres were usually packed and the doors guarded by four of the 'most quiet and serious students'.* Their job was to make sure that only students, doctors and perhaps, if there was room, 'those persons of good qualities' entered the theatre. There had been a few problems in the past with troublemakers from the lower orders getting in (there had also been a few cases where enterprising students had demanded payment from gawpers wanting to be admitted). The authorities were keen to stress that these were events for learning, not common entertainment.

* This was according to the official decree that detailed the strict rules governing public dissections.

The cadaver – a criminal allocated by the city authorities – was laid out on a slab at the centre of the room. The dissection was performed in constant reference to Galen's texts, and took place over a period of several days. Incisions were made and organs removed in strict order. The whole event was as much ceremony as lecture, with enough religious overtones to keep the powerful Church authorities happy. Tagliacozzi became so proficient at dissections that he was soon appointed professor of anatomy. It is therefore surprising that such a disciple of Galen and pillar of the surgical establishment should also turn out to be a great surgical innovator.

Tagliacozzi was fascinated with the idea that a damaged face might be restored. He started to develop a new branch of medicine: what he called the surgery of 'defective parts'. Although syphilis was one of the most prevalent causes of facial disfigurement, it was not the only way people could lose their noses. It was not unusual for them to be severed on the battlefield or in a duel. Unfortunately, even if their noses had been hacked off in an honourable way, syphilis had become so prevalent that people confused victims of the sword with the sinful victims of syphilis. More and more people were coming to Tagliacozzi desperate for a new face, but any attempt at reconstructive surgery was fraught with difficulties.

To be fair to Tagliacozzi, any surgery in the sixteenth century was fraught with difficulties. First, any operation had to be conducted without anaesthetic. Patients generally only agreed to the pain if the alternative was death, so surgery might be considered for a life-threatening condition such as a gangrenous leg wound. But could surgery be justified if it was only to restore a person's appearance?

The second problem was infection – the slightest cut in the skin could become infected and ultimately kill the patient. The only incisions surgeons made on a regular basis were for bloodletting; otherwise they preferred to stick with external treatments involving herbs, spices and possibly entrails. Overriding both these considerations was the problem of technique. If a surgeon were going to rebuild a nose, where was the skin going to come from? Attempts had been made to take skin grafts from donors (slaves or servants usually), but these had always been unsuccessful. The skin had to come from somewhere else on the patient's body. Tagliacozzi chose to take it from the arm.

However, it turned out you could not simply cut into the arm, remove a slice of skin and stitch it to the face; the patch would wither and die. There was also a good chance that the wound left on the arm would become infected. To remain viable, the skin had to remain connected to a blood supply. Tagliacozzi's solution was not without considerable pain, inconvenience and embarrassment for his patients (not to mention cost), but it was simple.

PROFESSOR TAGLIACOZZI INVENTS A CURIOUS OUTFIT


The patient had not left his house for many months. The shame of being seen in public would have been too much to bear. His face was shocking to look at – where he had once had a nose there were only two scarred hollow sockets. Even his wife made every excuse not to see him, although given that he lost his nose through syphilis, this was hardly surprising. Whereas only a few months ago the man had been out every day, he now lived for the most part in his bedchamber, visited by only a few trusted servants. It was a grim existence, and one that he hoped Professor Tagliacozzi would be able to rectify. Otherwise, he believed he would probably take his own life.

Tagliacozzi's knife is razor sharp, his movements rapid and precise. He slices the blade into the patient's flesh on the underside of the upper arm, making a cut about as long as a nose. He removes the knife and makes a further cut parallel to the first. He then makes a cut between the top of the two lines. The knife is so sharp and the incisions so quick that the patient feels hardly any pain. The cuts redden as blood seeps out. It drizzles down the man's arm and drips into a bowl on the floor. Tagliacozzi mops the wound with a handkerchief and moves on to the next stage of the operation. Sorry, sir, but this part is going to hurt.

The surgeon slips his knife through one of the cuts and passes it horizontally underneath the skin. The patient screams in agony as Tagliacozzi runs the knife backwards and forwards between the two parallel incisions. He slices through nerves, blood vessels and fat, gradually lifting the skin as he goes, pulling it away from the underlying tissue. Now the pain is becoming unbearable. The man is desperate for this terrible torture to end. Tagliacozzi's assistant struggles to keep the patient's arm still. It takes only a few minutes for the surgeon to finish, but for the man it feels like an eternity.

When all the cutting, slicing and scraping is finally over, the patient is left with a rectangular flap of skin on his arm and a gaping wound. Tagliacozzi carefully lifts the flap with his fingers and dresses the raw tissue underneath with strips of bandage that soon become sodden with blood. The raised skin, known as a pedicle, remains connected to its blood supply at the lower end of the rectangle, although the exposed edges are already healing. Now the surgeon needs to graft the skin to his patient's face.

When the patient raises his arm in front of his face, the pedicle rests across the empty sockets of the nose. Being connected to the patient's arm, the pedicle is supplied with blood and, with the help of a few stitches, will grow into the man's face. When the thousands of tiny capillaries and veins in the face have made their connections, the pedicle can be severed and the finishing touches put to the new nose. The problem is that it takes at least two weeks for the new blood supply to be established. In the meantime, the patient has to hold his arm across his face.

Try holding your arm up in front of your face so that your upper arm rests on your nose. Now try holding it there for two minutes. Hurts, doesn't it? Imagine how it feels to hold it for two hours. Or even two days. To get around this impossibly uncomfortable situation, Tagliacozzi designed a novel item of headgear. It consisted of a leather corset and helmet supporting a series of belts and straps. The straps held the patient's arm in place so that the hand rested on the back of their head. Their wrist was attached to the helmet to restrain movement, and straps around their head prevented the arm swinging from side to side and accidentally ripping the pedicle.

Tagliacozzi had this peculiar bondage outfit tailor-made for each patient. Once on, it had to remain on for two weeks – the patient's hand strapped across the top of their head, their elbow jutting out in front of their face, their movement and vision restricted. It was cumbersome and looked ridiculous, but people were prepared to try anything to restore their features.

The jacket and headdress were only part of Tagliacozzi's elaborate treatment plan. As the pedicle gradually started to grow into the stump of the nose, the surgeon insisted that his patients follow a strict diet. They were allowed meat – but it should be roasted, not boiled – and he advised that they avoid fish. At least there weren't any entrails involved. With the straps securely tightened on the corset, the patient was left groaning on his (or her) bed.

A fortnight later the surgeon returns to see how the patient is getting on. By now the top of the pedicle has grown into his nose. The tissue is still healthy and Tagliacozzi can sever the connection between the upper arm and the face. A quick slice with the knife and, much to his relief, the patient can remove the leather jacket and lower his arm.

After two weeks he, like most of Tagliacozzi's patients, finds his muscles so cramped that he can barely move. The stench when he takes off the leather jacket is somewhat overpowering. As for his appearance, if anything it has got worse. Where he had once had half a nose, he now has a flap of skin dangling in the middle of his face. In true Renaissance fashion, Tagliacozzi needed to become an artist.

Using splints, bandages and the occasional stitch, the surgeon starts to rebuild the nose. Over the next few weeks, he slowly sculpts his patient's new face. Three months after the first incision, the skin has grown together, the splints have done their job and the bandages can be removed. Carefully pulling out the final splint, Tagliacozzi holds up a mirror. His patient's new nose is revealed in its full glory. Slightly scarred and somewhat different in colour from the rest of his face, it is still a considerable surgical achievement. He can once again go out in public. Tagliacozzi was truly a miracle worker.

The surgeon published the first-ever book on reconstructive surgery in 1597. Within it he outlined his methods and included detailed diagrams to illustrate the various stages of nasal and other types of facial reconstruction. The techniques he devised would remain familiar to surgeons well into the twentieth century.

Unfortunately, after Tagliacozzi died in 1599 his reputation collapsed. The Italian Church had been growing suspicious of his activities. Now that he was in no position to defend himself, the Church summoned its investigation team: the tribunal of the Inquisition.

Tagliacozzi was accused of magical practices. He had modified the human face and in doing so had been interfering with the will of God. In the end the Church allowed his soul to rest in peace, although stories persist that Tagliacozzi's body was removed from its tomb and his bones dumped on unconsecrated ground.

At the time Tagliacozzi's method was a major advance on anything that had gone before, although his techniques built on more than two thousand years of surgical practice. The first recorded case of plastic surgery took place in India around 1500 BC. The Hindu epic poem Ramayana tells the story of Surpanakha, a beautiful temptress (some say a demon with magical powers). With her bewitching personality, Surpanakha attempts to seduce a young prince who is promised to another. She is sentenced to a brutal punishment for her actions and her nose is cut off. However, this is far from the end of the story. Rather than live with the disfigurement, she goes for reconstructive surgery.

An Indian medical text dated to around 600 BC gives an idea of the sort of treatment Surpanakha would have received. First, the doctor would have cut a nose-shaped flap in her forehead – narrow at the bottom, above the nasal cavity, and wide at the top. The incision would have been around a quarter of an inch deep, down to the periosteum, the thin fibrous membrane covering the skull.* The doctor would then have peeled the skin away from her forehead, making sure not to tear the narrow part at the bottom. This strip of skin, rich in blood vessels, would become the pedicle and keep the skin flap alive. Twist the pedicle around and bend it down and there you have a new nose. You also have excruciating pain and an appalling (nose-shaped) scar on the forehead. It was a crude technique, but better than having no nose at all.

* Periosteum membrane covers all bones, but the forehead is one of the few places on the body where the skin is right against the bone. Periosteum contains tough fibres of collagen and nerves, as well as blood vessels to supply the bone cells.

Surprisingly, despite Tagliacozzi's advances, the cruder Indian technique was still being practised by surgeons well into the nineteenth century. Seemingly reluctant to try any surgery that took more than a few seconds, Robert Liston (see Chapter 1) dismissed the Italian method as too tricky. The Indian operation, on the other hand, was 'less difficult in execution, not so liable to failure, and more easily undergone by the patient'.

In his book Elements of Surgery, Liston describes in detail his own variation on what he termed the 'rhinoplastic operations'. Liston suggests making a wax mould of the nose and then flattening it out so that it becomes a template for the skin flap. However, he confesses that this can be a difficult process and it is often more convenient to use a piece of cardboard (you can guess which method he used).

The card was held firmly by an assistant as the surgeon traced around it with a pen, 'or at once with a knife carried deeply through the integuments'. It is hard to imagine Liston bothering with a pen first. With the template removed, Liston describes pulling the skin away from the forehead using his finger and thumb. If it becomes difficult, he suggests the use of a hook. Finally, the flap is twisted around and placed over the area of the nose, the wound in the forehead is dressed and a couple of straws are stuck up the nostrils so the patient can breathe. Understandably, many people opted for false tie-on noses rather than endure the horrors of Victorian surgery.

However, it was another Liston innovation that revolutionized plastic surgery: anaesthetic. Before pain relief, surgery was the last resort of a desperate patient – whether it was to remove a diseased limb or fix a disfigured face. Now, though, a whole glorious new world of surgery was about to open up. People were no longer coming to surgeons to fix their faces: they wanted to improve their faces. Nose jobs, smaller breasts, facelifts or bigger lips – there was nothing surgeons wouldn't try. And with infection defeated by antiseptic techniques, operations were becoming much safer.

A new era of cosmetic surgery had arrived, and surgeons (some more qualified than others) were, once again, in the exciting business of experimenting on their patients. Bizarrely, rather than perfecting operations to move flaps of skin around, they developed operations that involved inserting a whole range of novel substances beneath the skin. It seemed there were few products of the Industrial Revolution that weren't brought to the operating table. Surgeons attempted rebuilding noses with ivory, they experimented with metal, celluloid and gutta percha (a substance derived from tree sap); they tried oil and coal extracts; even bits of animal cartilage. One surgeon brought a live duck into the operating theatre, slit its throat and attempted to repair his patient's nose with the bird's breastbone. They notched up their failures to experience until, finally, they hit upon the perfect new substance.

GLADYS DEACON: A CAUTIONARY SURGICAL TALE

Paris, 1903


Twenty-two-year-old Gladys Deacon lay in bed contemplating her own beauty. She was, undeniably, exceptionally beautiful. She was also extraordinarily vain.

Intelligent, charming and wonderful company, Gladys was all these things and more. Why, hadn't a young gentleman told her that this very evening? He was handsome certainly, but a mere plaything to Gladys, who had set her sights on marrying into royalty (or landed gentry at the very least). Still, it was nice to be admired; although few people could come as close to admiring Gladys as much as Gladys herself.

Raised in Boston, Massachusetts, she moved in all the right circles. She then burst on to the European social scene, mixing with aristocrats and artists, princes and politicians. A friend talked of how Gladys traversed Europe 'like a meteor in a flash of dazzling beauty'. The press adored her, men courted her, other ladies envied her. She was becoming famous for being famous – a true Edwardian celebrity. But as she lay on her bed thinking about herself, she started to have doubts. Could she possibly become more beautiful?

Like many Edwardians, Gladys was fascinated with the classics and the concept of classical beauty. She toured the galleries and museums of London, Paris and Rome, examining statues and studying paintings. She admired the profiles of Hellenic faces; their strong foreheads and straight noses. She even took to recording the distances between the eyes and noses of statues to see how they measured up. But when she compared herself with them, her observations brought her to an alarming conclusion: she wasn't perfect after all. Her nose dipped between her forehead and the tip, creating a slight hollow. She wanted a straight classical nose, and she knew just what to do to get one.

Gladys went to see a professor at the Institut de Beauté in Paris. He examined her and advised that she try the latest advance in cosmetic surgery: paraffin wax. Unlike previous innovations, the wonder of this new treatment (invented only a few years before) was that there was no actual surgery involved. All the surgeon had to do was inject a measure of hot paraffin wax under the skin: as it hardened, he could mould and shape it to create the perfect profile. Paraffin wax had been injected into faces, breasts, buttocks and even the occasional penis. It really was a remarkable invention. It sounded almost too good to be true.

The surgeon wears thick, black rubber gloves as he prepares the paraffin. The solid white block of wax is gradually turning to a slushy liquid as he heats it on a small oil burner. The large glass syringe, with its formidable wide steel needle, is lying alongside in a basin of hot water. The surgeon has learnt from experience that unless the syringe is also hot (hotter by several degrees than the wax), the paraffin will solidify before it can be successfully injected. Reaching over, he checks the temperature of the paraffin with a thermometer. It is a careful balance: too cold and he can't inject it, too hot and it will burn the patient. The ideal temperature is around 30°C, but it is difficult to get it just right. He has heard of cases where the skin has simply sloughed away from the patient's face, presumably due to excessive heat. Still, there are risks with all types of surgery.

Gladys lies back on the couch. She has tied back her hair to expose her beautiful, smooth, (near) perfect face. The surgeon's assistant dabs the bridge of the young lady's nose with some dilute carbolic acid to clean her skin. The surgeon sits on a stool beside her, the pan of hot melted paraffin wax and warm syringe at the ready. She gasps as he makes a small nick in her nose with a scalpel. He places the tip of the needle in the hot wax and draws the asbestos piston (rubber would have melted) of the syringe upwards to fill it. Even with gloves on, the surgeon can feel the heat as he places his fingers through the loops at the top of the syringe and prepares for the injection.

Gladys is proud of how brave she is being. She has been warned that it will be painful, but pain is surely a small price to pay for perfection. As the surgeon sticks in the broad needle and depresses the plunger, Gladys feels as though molten metal is being injected into her head. The paraffin wax squirts out through the needle and beneath the skin of her nose. The surgeon keeps pressing until the syringe is almost empty, then he flings it aside and begins to mould Gladys's new face.

He has between fifteen and thirty seconds to get it right. The fingers of his bulbous gloves push, knead and press. He glances down at a picture Gladys has provided so that he can check his work. He runs his fingers along her nose, smoothing any bumps, moulding the paraffin like putty beneath her skin. The paraffin wax is hardening rapidly and time is running out. The surgeon presses as hard as he can to stop the wax clumping. A few seconds later and it has set; but he is finished. Gladys Deacon has a new nose.

The surgeon explains to Gladys there may be some swelling at first, but this will soon disappear. In just a few days, he tells her, she will have a classical nose to be proud of. He applies a compress of lint dipped in icy water to numb the pain and sends her home.

The swelling was indeed quite bad to start with. Only it didn't get any better. Instead it got worse, the bridge of her nose bursting into an angry open sore. Doctors were summoned to examine her, but when she was questioned Gladys denied having had any surgery. Instead she blamed her inflamed features on an accident, telling people she must have knocked it. But the nose got worse: the wax began to wander; lumps appeared beneath her skin. Her beauty was slowly being destroyed from within. Far from achieving the classic looks of a Greek statue, her quest for perfection was turning her into a freakish waxworks dummy.

It was little consolation to Gladys that she wasn't alone. Despite the ringing endorsement of many eminent surgeons, including England's Stephen Paget, who recommended the use of paraffin wax in the British Medical Journal,*others had begun to notice that these injections often led to unwanted side effects. In fact, the list of side effects was alarmingly extensive. The condition was even given a name: paraffinoma, although some doctors simply called it wax cancer.

* Stephen Paget was considered one of Britain's finest surgeons. In a gushing article in the September 1902 edition of the British Medical Journal, he described how paraffin wax was simple to use and produced excellent results. In his own practice, he said, the outcome was 'absolutely satisfactory'; he even gave the name of the company from which the paraffin wax could be purchased. To be fair, the wax did sometimes produce excellent results but, given that no one had carried out any proper trials, it is impossible to know what proportion of injections was successful and what proportion ended in disaster.

Symptoms ranged from the odd lump to wide abscesses where skin withered and died. Paraffinoma caused infection and destroyed muscle. If the paraffin got into the bloodstream it led to blood clots in the lungs and was held responsible for blindness, strokes and heart attacks. The price of perfection was quite possibly death.

In his 1911 book on plastic surgery, American surgeon Frederick Kolle highlighted the dangers of paraffin wax injections. He also warned doctors against the 'unreasonable' demands made by patients who were 'bent upon having the alabaster cheek ideal of the poets, the nose of a Venus, the chin of an Apollo'. He referred to these people as 'beauty cranks' – those seeking perhaps 'very desirable marriages'. Surprisingly, it seems he had never met Gladys Deacon.

By the 1920s the wax injection had really taken its toll on poor vain Gladys. She wore a hat low over her face to disguise the worst ravages of paraffinoma, but female rivals recorded bitchily how the wax had given her face the appearance of a gorgon. Others remarked that she looked heavy jawed, her hair too yellow, her lips too red. She no longer looked like a lady (the implication being that she looked more like a whore). A princess who had once been jealous of Gladys noted with ill-disguised satisfaction how the wax had run down her face to create blotchy patches in her neck.

However, while society mocked her for her medical mistake (behind her back, of course), Gladys continued her climb up the steps of the social ladder. In 1921 she finally made it into the British aristocracy by marrying the 9th Duke of Marlborough and taking up residence at Blenheim Palace in Oxfordshire. But despite being a duchess, she was becoming more and more depressed.

By the 1940s, her marriage having failed, she was to be found living in a ramshackle farmhouse. She slept on a broken mattress surrounded by the squalor of cats, rotting food, papers and books. Gladys was becoming increasingly frail, isolated and paranoid, and it wasn't long before four men in white coats came to literally drag her away.

Gladys Deacon died in her sleep in a Northampton psychiatric hospital in 1977. The funeral was poorly attended. Most people had forgotten Gladys Deacon, Duchess of Marlborough. People said that in her later years she would sit by the fire, letting the heat of the flames soften the paraffin beneath her skin so that she could move it around her face. Gladys never did get the perfect nose.

THE FACES OF WAR

Queen's Hospital, Sidcup, Kent, 1917


It was difficult to look at Lieutenant William Spreckley without experiencing a feeling of utter revulsion. Even the man himself sometimes wished he had been killed when the bullet hit him. His existence, he felt, was almost a living death. He had been passed from the trenches at Ypres to casualty station to hospital before finally ending up in Sidcup, but he didn't hold out much hope for his chances. He would be disfigured for the rest of his life, shunned by society – perhaps even by his own family.

William had a sad, haunted look in his eyes. Although lucky to be alive, he was feeling sorry for himself. Bullets sliced through whatever material they met – whether it was wood, metal or human flesh. Most of his comrades had been cut down: some were killed instantly, others wounded fatally, the rest permanently disabled. William could remember a bright flash of light but, strangely, experienced little pain. He was stretchered away to the crowded tents of the field hospital, where he expected to be left to die. Instead, over the next few weeks he started to recover. He knew his face was damaged, but the nurses and doctors refused him a mirror. The surgeons stitched him up and nurses changed his dressings. By the time William arrived at Sidcup his wounds had healed well. He was fit and healthy. Everything was fine, except for his face.

Instead of a nose he had an ugly, gaping hole. The skin had grown inwards, and what remained of the interior – red tissue and bone – could be seen through the black hollow. The left side of his face was distorted around the hole; a series of lateral scars had healed to draw down the skin beneath his eye, revealing the lower part of his eyeball. But this was nothing compared to the missing nose.

Queen's in Sidcup was the first hospital in the world dedicated to plastic surgery, and the surroundings couldn't be more different from what William had experienced in the trenches. Built in the grounds of a stately home, the hospital was encircled by gardens and tall trees, and even boasted a beautifully manicured croquet lawn. The single-storey wards, treatment rooms and operating theatres were arranged in a horseshoe shape around a central admissions block. Each ward was designed to hold twenty-six beds and included a veranda so that patients could lie outside in the fresh air to help their convalescence (fresh air was considered vital for recovery).

Queen's was the brainchild of surgeon Harold Gillies. He had entered the war as a junior Red Cross doctor in 1914, and had been horrified by the injuries he saw. But Gillies was even more shocked to discover how little British surgeons were able to do to piece soldiers back together. Their techniques were primitive and wholly inadequate. No one had anticipated the terrible carnage – the faces that were blown apart, the missing noses or jaws, the melted flesh and jagged scars. All the surgeons could do was draw the edges of the wounds together, wait for the scars to heal and post their patients back to the trenches to fight another day.

Gillies decided to dedicate his life to plastic surgery, and taught himself everything there was to know about facial reconstruction. Over the next three years (while continuing to work in hospitals in France and England) he studied obsessively, wading through textbooks and research papers. He even enrolled in an art school so that he could learn how to draw detailed diagrams of his surgery. Eventually, he managed to convince the army medical authorities that they needed a dedicated hospital to treat facial deformities. When Queen's Hospital opened in the summer of 1917, Gillies – now Britain's foremost plastic surgeon – was appointed to run it. He was ready to put his vast knowledge of plastic surgery to the test.

William Spreckley was one of the first patients to be admitted to the new hospital. When Gillies examined the young soldier he decided he could do better than simply give Spreckley a new nose. He wanted to improve on the crude efforts of previous generations of surgeons and give Spreckley a nose that really looked like a nose, not some crude flap of skin twisted down from the forehead or grown from the upper arm. He made careful measurements of Spreckley's face and set about planning a series of intricate operations.

Because Spreckley's nose was missing completely, Gillies planned to re-create both the skin and the cartilage supporting it. Rather than repeat the disastrous experiments of his Victorian predecessors and use animal cartilage or synthetic alternatives, Gillies chose to take the cartilage from elsewhere on his patient's body. After drawing up a complicated set of diagrams and technical notes – he believed in the importance of preparation – he was ready to operate.

In the whitewashed, airy operating theatre, with its powerful electric lighting and enormous picture windows, Lieutenant Spreckley is put to sleep.* Gillies, dressed in his sterilized surgical gown, his hands washed in alcohol and covered with fresh rubber gloves, is ready to make his first incision. He cuts into William's chest. The first part of the operation is ingenious and involves removing a small, rectangular piece of cartilage from the soldier's ribcage. Gillies intends to shape this into the support for the nose.

* A major advance in anaesthetics was made at Queen's Hospital. In 1919 Ivan Magill developed endotracheal intubation – the technique of passing a rubber tube through the patient's nose or mouth to allow the gas to flow directly into the trachea. This was not only a more precise means of delivering an anaesthetic, it also overcame a problem that had plagued reconstructive surgery. During the many hours surgeons spent leaning close to their patients' faces, and therefore the gas intake pipe, they often ended up breathing in the anaesthetic. It was not unknown for surgeons to fall asleep during operations.

Cutting the cartilage carefully, he bends it along the middle and then cuts away part of the central section to leave a narrow stem. He is left with a shape that resembles an arrow. It has a wide piece at one end, a narrow shaft and a bow-shaped tip. The wide part will form the bridge of the nose; the lower arrowhead will support the nostrils. Once Gillies is confident that the cartilage is the right shape, he slices open a flap of skin on William's forehead and transplants the cartilage under the surface.

When Spreckley recovered from the operation, he looked even more deformed than when he had first been admitted to the hospital. Instead of a flat forehead – which had been undamaged by the bullet – he now had a pronounced, arrow-shaped bump under his skin. The arrow was pointing diagonally upwards from the centre of his lower forehead towards the line of his hair. Gillies was, in effect, growing Spreckley a new nose in the middle of his forehead. Several weeks later, once Spreckley's forehead was fully healed, Gillies moved on to the next operation.

Cutting carefully, to leave the cartilage intact, Gillies slices a flap of skin from Spreckley's forehead. Making certain not to damage the pedicle, he twists the skin around to form a new nose. The cartilage keeps the structure from collapsing, although the resulting protrusion is hardly attractive. Beneath the angry, triangular-shaped scar on Spreckley's forehead, the new nose balloons out across the soldier's face. He has gone from having no nose to having a swollen, comic representation of a nose. It is horrible. Other patients joke that Gillies has transplanted a trunk in the middle of the poor man's face. Even the surgeon himself remarks in his case notes that 'the new, bloated columella stuck ahead like an anteater's snout and all my colleagues roared with laughter'. But the surgeon is far from finished.

The operations continue. The swelling gradually subsides and the pedicle is severed. Gillies closes the forehead scar and cuts away the excess tissue. He shapes the nostrils and defines the shape of the new nose, cutting or pulling in excess skin. By the time Spreckley is discharged his face is almost as good as new. The transformation is truly remarkable. Looking at him, you would never know that his nose had been rebuilt from his ribcage and forehead.

Spreckley was so grateful that he named his son Michael Gillies in honour of the surgeon who had restored his face.

The techniques Gillies had used for Spreckley were courageous, innovative and largely experimental. Although his operations were meticulous and his antiseptic techniques rigorous, there was always a risk that something could go wrong. The thing Gillies feared most was infection. If a wound became infected, there was little he could do.* Nevertheless, the cases that were coming to the hospital demanded that he try even more daring operations.

* There were no effective antibiotics until the discovery of sulphonamide drugs in the 1930s. By the end of the Second World War, military surgeons also had penicillin at their disposal, which dramatically cut the number of hospital deaths.

A STEP TOO FAR


Second Lieutenant Henry Lumley of the Royal Flying Corps was barely recognizable as human. His face was no longer covered in skin – it had melted into a red shiny mask of thin epithelium. His eyes were wide sockets with no eyelids or brows. His nose was pulled upwards, his lips – if they could even be called lips any more – were wide and inflamed, and his mouth scarred.

Lumley had never seen combat. During his first mission, in the summer of 1916, his plane crashed to the ground in a ball of flames. Pilots were not issued with parachutes, so when the fuel tank caught alight, Lumley was trapped in a fireball of petrol. His face, scalp, hands, fingers and legs were all severely burnt. Some areas of his head were protected by his helmet and scarf, but no one knew how he had managed to survive. He might well have been better off dead. Lumley was admitted to Queen's Hospital on 22 October 1917. He had spent the previous year being patched up by various medical centres before he was finally referred to Gillies. It was the surgeon's toughest case yet.

Over the next month, Lumley was made as comfortable as possible while Gillies planned a series of operations. The surgeon proposed using skin from the pilot's chest to re-create his face. He would connect it with pedicles from the pilot's neck, and augment it with flaps of tissue from his shoulders. Gillies also decided to use paraffin wax and even attempt using a skin graft from another patient.

The first operation to prepare Lumley's face goes reasonably well and the patient seems to be making good progress. The second operation is about to begin. Lumley is anaesthetized on the operating table, his body propped up so his head is high. He has been stripped to the waist and his chest painted yellow with iodine. On the skin of his chest Gillies has drawn a face. There are spots for the eyes, marks for the nose and a long, narrow gap for the mouth. This outline will be Lumley's new face. It is a daring plan.

Gillies cuts and scrapes away the scar tissue from Lumley's face, leaving it horribly raw and red – blood seeping through to cover it in a glistening sheen. He then carefully cuts along the pencil lines on Lumley's chest until he has created a large (face-shaped) flap of skin. He lifts this up and places it across the airman's face, making sure to line up the holes for the eyes, nose and mouth. Then he begins to sew. Carefully and methodically, he attaches the new face across the remains of the old. When he has finished, he dresses the chest wound. The whole operation takes five hours. The surgeon is exhausted. The patient is terribly weak, his pulse faint. Now it is a question of waiting.

The first day after the operation, Lumley is definitely improving. The blood supply from the pedicles to the face seems to be working. On the second day, the graft starts to become infected. The doctors work desperately to stop the infection spreading. They try massaging the skin, pricking it with needles and cupping it (see Chapter 1) to increase the blood supply. By the third day, Lumley's new face is completely gangrenous. The pedicles from the shoulders are no longer supplying any blood and are gradually withering away.

By the tenth day, the dead skin has to be scraped off. Gillies records in the case notes that a foul discharge was expelled. The remaining pedicles are now only barely attached, and Gillies does what he can to save the blood supply. The doctors cleanse the wounds and spray them with paraffin wax. Later that day the patient is moved to an open-air hut in the hospital grounds.

Day fourteen and all the grafted skin has almost completely come away. For once, however, Gillies can report some good news. Lumley's chest seems to be healing and his face is no longer so infected. On 3 March Gillies starts a new treatment, using an ultraviolet lamp to encourage healing on the chest. By this time he has given up trying to save the face graft; he is now desperately trying to save the man's life.

Second Lieutenant Henry Lumley died of heart failure on 11 March 1918. Gillies had pushed plastic surgery to its limits, but with Lumley he realized that he had gone too far. Gillies wrote that his 'desire to obtain a perfect result somewhat overrode surgical judgement of the general condition of the patient'. He added, 'Never do today what can be honourably put off until tomorrow.'

Despite this terrible setback, Gillies achieved some fantastic advances in plastic surgery. Probably his greatest innovation was to adopt a Russian idea known as the tube pedicle. Instead of grafting exposed flat pedicles of skin which, as Lumley's case had proved, were prone to infection, he rolled the pedicle into a tube. This meant that all the delicate living tissue was enclosed within an outer layer of dead skin, providing it with a waterproof and infection-resistant cover.

But even the tube pedicle had its limitations. Skin could be moved only between adjacent sections of the body. A pedicle could be taken from the shoulder to the face, or the chest to the chin, for instance, but it was impossible to use the technique to take skin from the leg to the face unless the patient curled up in a ball for weeks on end. This made reconstructive surgery for a patient with burns across the whole upper body practically impossible.

As he was contemplating this problem, Gillies had a genuinely original idea; he called it the waltzing pedicle. What he would do was cut a pedicle from the leg and swing it upwards to attach it to the arm. Then, once the blood supply was established after a couple of weeks, he would cut the end still attached to the leg and swing it from the arm up to the face. By waltzing pedicles in stages to the site where they were needed he could safely take skin from anywhere on the body.

With the German push of 1918, more and more casualties were arriving at the hospital. Gillies worked all the hours he could while training up a new generation of plastic surgeons. Soon the wards were filled with patients covered in tubes of flesh; hoses of skin protruding from their legs, arms and faces; pedicles waltzing up their bodies.

Take the case of Private A.J. Sea, for instance, admitted to Queen's Hospital in June 1919. Since his injury, Sea had spent a year in military hospitals, but there was only so much the surgeons could do for him. In April 1918 he had been shot in the chin. The bullet had shattered his lower jaw, ripping away the floor of his mouth, taking the skin, bone and muscle with it. An ugly metal brace replaced his lower lip, keeping his jaw from falling apart. Sea's chin flopped uselessly, a few remaining teeth on his upper jaw stuck out at precarious angles. The twenty-three-year-old had to take all his sustenance through a straw. Like most patients who arrived at Sidcup, his eyes had the haunted look of a survivor who had endured more pain and suffering in a few months than anyone should experience in a lifetime.

The process to rebuild Sea's face was long and painful. The surgery was meticulously planned and the patient well prepared. The first operation was scheduled for August 1919, when a tube pedicle was cut from the soldier's chest and attached to his forearm. In October the end of the pedicle still attached to his chest was cut and attached to his missing chin, where it was held in position by straps. Six weeks later the surgeons took the end of the pedicle that was still attached to his arm and sutured it to his chin. The three operations were successful but, if anything, Sea's appearance was worse than ever. He now had a loop of skin passing beneath his mouth like a handle.

In March 1920 a large tube of skin was taken from his right shoulder. In September (more than a year after admission) a pedicle tube was taken from his neck, and work started to build the lining for the floor of Sea's new mouth. By December 1920 the private had undergone a total of ten operations, and in between he had received countless dressings, X-rays and examinations. By now Sea's chin was a dangling sack of skin covered in lines of stitches. Attached to it was a pedicle that passed around his neck and disappeared into the back of his shoulder. Another six operations followed over the next six months, until in August 1921 – two years after the surgery started – Private Sea was sent to a convalescent home to recover.

Sea was finally discharged from hospital in November 1922. His face was completely rebuilt. Although still disfigured, he had a mouth, jaw and lower chin. His broken teeth had been replaced by dentures, and his mouth had lips. Despite some scarring on his face and neck, he looked perfectly presentable. He would have only limited movement in his jaw, but at least he now had a jaw. Private Sea's life had been transformed. The last picture taken of him before he left the hospital even suggests that he was trying to smile.

In total, more than ten thousand operations were performed by the surgeons at Queen's Hospital. In all, only fifty men were lost – an incredible achievement given the ambition of the operations and the lack of antibiotics. Without surgery, many of the men might have survived, but with faces so damaged that their lives would have been a living hell. Gillies did his best to give his patients back their dignity.

Harold Gillies left Sidcup in 1919 to work on a definitive textbook of reconstructive surgery and set up a private practice. One of his first patients was recruited in an ethically dubious fashion while Gillies was staying at an inn during a fishing trip in Derbyshire. He noted that the daughter of the innkeeper was a 'comely lass' but she had a 'fearsome nose'. While he was out for the day, Gillies left a draft of his new book on the dressing table, open at the section about nose reconstruction. When he returned to London the girl contacted him and asked to be taken on as a patient. Gillies later admitted that it was a 'disgraceful' way of obtaining work, but at least the girl got a prettier nose.

Gillies was finally knighted for his services to surgery in 1930, although many people argued that the honour should have come years before. By that time he had accumulated piles of letters from grateful patients – from soldiers suffering with shattered jaws or burnt faces to children with harelips or cleft palates. Gillies' surgical skills had touched thousands of lives. He also had a reputation for kindness. He was known sometimes to waive the fee for those who could not afford to pay. The techniques he developed in Sidcup would be taken up by plastic surgeons around the world, and twenty years later would be adapted for a new conflict with even more terrible challenges.

MCINDOE'S ARMY

Somewhere over England, 16 March 1944, 11.20 p.m.


Something had gone wrong and there was nothing the crew could do. The Wellington bomber was plummeting towards the ground. It dropped 300 feet in only a few seconds, then smashed into the earth, its tanks full of fuel. The explosion lit up the night sky and flames tore through the twin-engine plane. The Wellington's fuselage was covered in stretched fabric, and this burnt like paper, rapidly peeling away to reveal the metal skeleton underneath. Nineteen-year-old navigator Bill Foxley forced open the plastic dome* on top of the aircraft and began to scramble to safety. Remarkably, he was hardly injured; an incredibly lucky escape.

* The dome or 'astrodome' was usually used for navigation. It enabled the navigator to see the stars, and he could use a sextant to fix the aircraft's position. The dome also doubled as an upper escape hatch.

Then Foxley heard the wireless operator's cry for help. He could hardly leave his friend to be cremated, trapped within the disintegrating airframe. Foxley lowered himself back through the hatch. The heat was unbearable, a violent wall of scorching flame. With the adrenalin pumping and the aircraft falling apart around him, Foxley hardly noticed that the skin on his hands was being seared on the smouldering metal struts, or that the flesh on his face was being stripped away by the heat. He reached his comrade and pulled him out. It was only when Foxley was well clear of the aircraft that he realized how badly he was now injured. His whole body seemed to be on fire.

He was admitted to the Queen Victoria Hospital in East Grinstead, some forty miles south of London. The Queen Victoria was the Second World War equivalent of Gillies' Queen's Hospital at Sidcup, and most severely burnt airmen ended up there. The men's recovery was overseen by Gillies' cousin, the brilliant and charismatic surgeon Archibald McIndoe. His job was to rebuild the airmen – ideally so that they could return to battle – but at the very least so that they could live a normal life after the war. With aviation fuel burning at temperatures of around 700°C, the surgeon faced an enormous challenge.

At the beginning of the war the majority of casualties had been airmen in Hurricanes and Spitfires defending the skies over southern England during the Battle of Britain. It was a horrendously dangerous occupation, and almost every day pilots would fail to return from their missions. The high-performance aircraft were packed with fuel, so if they were hit, the pilots had a good chance of being incinerated.

Both types of aircraft carried fuel tanks between the cockpit and the engine, but the Hurricane also had a 25-gallon tank in each wing. Unfortunately, a design flaw in the early Hurricanes meant that there was no fireproofing between the wing tanks and the cockpit. If a tank blew up, the cockpit became an oven surrounded by flame. Pilots were urged to keep the cockpit hood closed for as long as possible. Once they opened it, the flames tended to be drawn inwards. One airman described how he saw the dashboard melt and run like treacle before he was able to haul himself clear. Unlike in the First World War, at least these pilots had parachutes. However, bailing out into the English Channel was not a pleasant prospect because the icy salt water stung their wounds and hypothermia quickly took hold.

As the war progressed and the Allied raids on Germany intensified, more of the casualties were from bomber crews. There was a never-ending stream of new admissions to East Grinstead. Injuries ranged from shrapnel wounds to fuel burns. One patient was even admitted with frostbite. The rear door of his Lancaster had been blown open and his fingers had been frozen to the fuselage in his efforts to get it shut. To reconstruct these airmen, McIndoe had adapted and refined the techniques developed by Gillies during the First World War.

By 1944 the procedures were well established, the hospital well equipped and the staff well versed in caring for the victims of severe burns. Patients were immersed daily in specially designed saline baths to prevent infection and help their wounds to heal; new ways had been developed to deliver anaesthetics during the increasingly long and complex operations; and by the end of the war patients were being treated with penicillin. But, above all, McIndoe relied on the waltzing tube pedicle.

Ward Three of the East Grinstead hospital was bright and clean. There were fresh flowers on the tables, but nothing could disguise the nauseating smell of burnt flesh. Visitors, already desperately trying to cope with the visual onslaught, would frequently gag on the acrid stench. The beds were arranged in two long rows, and walking past them you could see the various stages of reconstructive surgery. Some patients were swathed in bandages, some had slings, but most had faces hung with pedicles – long hoses of skin that would soon be noses or jaws, lips or chins.

For the staff at East Grinstead, Bill Foxley was another typical case. Most of the skin on his face had been vaporized. It was distorted and ugly. His upper lip was burnt away, and the lower part of his nose had melted. It hung like dripping candle wax, leaving his nostrils flared upwards. His flesh was blistered and glistening, red and raw. His right eye was little more than a slit, blinded by the fire. His left was inflamed. Neither eye had brows or lashes. Worse were his hands. They resembled swollen gnarled stumps, the fingers fused together into a ball of flesh – a coagulated mass of tissue, bone and muscle all melded into one.

McIndoe's task was to rebuild Foxley's distorted face and do what he could for the airman's horribly damaged hands. Over the next few months Foxley had a series of operations to gradually restore his features. First, the surgeons took a tube of skin from his shoulder to his nose. Three weeks later it hung from his cheek to his nose giving his head the appearance of a jug. Finally, after a further three weeks, they used the tube to rebuild his upper lip. Nine weeks later the waltzing pedicle had done its job: Foxley's face had been successfully rebuilt.

The results of McIndoe's operations were even more impressive than Gillies' achievements during the First World War. Although Foxley's face was still somewhat distorted, in only a few weeks McIndoe had given him a new nose, lips and glass eye. The surgeons had also managed to separate what was left of his fingers and partly rebuild his hands.

But McIndoe was more than just a great surgeon; he was also a great psychologist. The patients at East Grinstead did not spend their days lying in bed; they were encouraged to get out and about. After all, most of these men were young and fit. Until their injuries, they had lived life to the full. Indeed, airmen were notorious for their fast living, and keeping them cooped up would do nothing to help them.

Most of their injuries were external and cosmetic, which meant that they were perfectly capable of moving around. So, with tube pedicles dangling from their faces, they could be found playing football in the grounds, drinking beer in the local pubs or watching films in the town cinema. McIndoe made great efforts to ensure that his patients were integrated as much as possible into the East Grinstead community. He encouraged local people to visit the hospital, and gave talks to explain the work that was done there. As a result of his efforts, the men were received as guests in local homes and were treated with respect in pubs and restaurants.

The town was proud to play host to the airmen and became part of their therapy – a stepping-stone between the hospital and the wider world. A world where perhaps they would not always be treated so well. During the First World War Gillies had found that, despite his best efforts, his discharged patients met with little public understanding. Their return to Civvy Street had sometimes been brutal. They were haunted by their looks and shunned by society. Many led isolated lives or ended up in dead-end jobs – selling matches or begging. One former patient even found employment as an 'elephant man' in a travelling circus. Many suffered from depression. Some committed suicide.

McIndoe wanted his patients to be treated as the heroes they were, not freaks to be locked up behind closed doors or laughed at in a circus. He encouraged the wounded men to support each other – to wear their injuries with pride. They called themselves the Guinea Pig Club, produced their own magazine, had a little emblem (a guinea pig with wings) and even their own anthem. This is the first verse:

We are McIndoe's army, we are his guinea pigs.

With dermatomes* and pedicles, glass eyes, false teeth and wigs. A night out with the Guinea Pig Club could be a peculiar thing to witness. Their favourite haunt was the Whitehall restaurant in East Grinstead, where the manager, Bill Gardener, became almost as important to their rehabilitation as McIndoe himself. Gardener took a special interest in the men from Ward Three. He drank with them at the bar, but made sure they did not drink too much. He chatted with them, helped them laugh and managed to steer them away from moodiness or depression. Other places in town were similarly accommodating. Seats were reserved for the Guinea Pig Club at the cinema, and they were regular guests at local dances.

* A dermatome is a surgical instrument used to cut away slices of skin for grafting. In the song, however, it could equally be referring to the slices of skin themselves.

At any of these places you could see badly disfigured men, some with bandages, most with tubes of flesh hanging from their faces. They would be seen laughing, joking or chatting up the local girls. Some had only stumps for hands and needed help to drink. Their friends would lift the drinks to their lips and assist them later when they needed to go to the lavatory. Often these strange-looking men were accompanied by nurses from the hospital (whom they would also be chatting up). Gradually, the men of the Guinea Pig Club overcame their injuries and regained their dignity. Many of them married local girls, and very often local nurses.

Word of the hospital spread and soon gained national attention through newspaper and magazine articles. Britain's most popular entertainers came to visit the famous heroes of Ward Three and give performances in the town. Joyce Grenfell and Flanagan and Allen were among the stars to entertain the Guinea Pigs. The hospital was visited by senior politicians and military figures. The local paper reported that the hospital's work 'and the work of their splendid staff was known throughout the world'.

McIndoe's army was a triumph. The surgeon restored the faces of Allied airmen but, above all, he restored their pride. Bill Foxley is one of those proud survivors and attends the regular reunions of the Guinea Pig Club. Like many of McIndoe's patients, he looks back on his time at East Grinstead with affection. He recalls an occasion when the surgeon took a group of them into London. 'It frightened the life out of people,' he says, 'but that was all part of the game.'

Between them, Gillies and McIndoe had also restored the reputation of plastic surgery. They had developed new techniques and made tremendous advances in improving the appearance of their disfigured patients. But as 'beauty crank' Gladys Deacon had demonstrated, and as Gillies had discovered with the innkeeper's daughter, you didn't need to be badly injured to seek the advice of a plastic surgeon. There were lots of people who wanted to change their appearance, and for the gifted surgeon a whole new post-war world of opportunity was opening up.

A WHOLE NEW USE FOR A TUBE PEDICLE

London, 1946


Harold Gillies had been working as a government consultant during the war, but now he was ready to go back into full-time private practice. The rich and famous came to his house, just off Harley Street, for discreet facelifts, tucks or enhancements. He applied everything he had learnt from battle wounds to the fading faces of Knightsbridge and Mayfair, and was pulling in the equivalent of some £1.3 million a year. Plastic surgery had made his reputation, but cosmetic surgery was making him rich. Now aged almost seventy, he was about to perform an operation that would guarantee him a place in the history books.

Laura Maude Dillon was born the wrong sex. She spent her life convinced that she should have been a man. She dressed in men's clothing and could pass herself off as a man in the street. But this wasn't enough for Laura; she wanted to be a man. She was determined to transform herself physically into the opposite sex. When she made the decision in the late 1930s this was hardly an easy thing to do.

First, there were legal and social implications – how on earth would society treat her/him? Would she even be allowed to do it? There were other practical problems too. No surgeon had ever tried to turn a woman into a man before. But Laura was determined, and she managed to persuade a doctor to prescribe testosterone tablets. Her voice and appearance began to change and, during the war, she underwent a double mastectomy to remove her breasts. She was becoming androgynous, but was not yet a man. Finally, Laura was put in touch with Harold Gillies.

During a series of operations, carried out in the utmost secrecy, Gillies used his tube pedicle technique to build Laura a penis. First, he cut a tube of skin from her side and looped it around to her crotch. He then filled the tube with a frame of cartilage to give it bulk and structure. Once the blood flow was established, the end of the tube connected to her side was severed and the appendage gradually shaped into a penis. Finally, a rubber tube was connected to her urethra so that she could urinate through the new organ. Thanks to the tube pedicle, Laura became Michael. Gillies had successfully performed the world's first female to male sex change operation.

Michael's new penis was only cosmetic – he would never be able to achieve an erection, which meant he could never have a full sexual relationship. But being a man made it a lot easier to have a career. Michael enrolled in medical school under his new legal name and eventually qualified as a doctor. He even wrote a book, describing people who were born with the mind of one sex and the body of the other. No one reading the book guessed that he was actually describing himself. In fact, few people would ever have known that Michael was born Laura if it had not been for his aristocratic background.

Michael's brother was Sir Robert Dillon, the 8th Baronet of Lismullen. In Debrett's guide to the British aristocracy Michael was listed as Sir Robert's heir. However, in the rival publication, Burke's Peerage, Sir Robert's heir was given as Laura. The birth dates of Laura and Michael were the same, and it didn't take long for someone to realize that they were the same person. During research, the editor of Debrett'shad come across the amended birth certificate that had transformed Laura into Michael.

The story broke in 1958 – and what a story it was. A sex scandal involving the aristocracy: what could be better? The world's press were all over it and set about tracking Michael down. They found him on a freighter in Philadelphia, where he was serving as the ship's medical officer. Reporters persuaded the reluctant doctor to give an interview. He certainly looked like a man. He was described as bearded and smoked a pipe. Dillon told the newsmen that he had been born suffering from hypospadias. This is a condition found in males where the opening of the urinary tract is not at the tip of the penis. Dillon had never in fact suffered from hypospadias; physically, he had been born a perfectly healthy girl, but was justifiably unwilling to give the reporters the truth. He said that he had undergone the operations to make him a more complete male.

He hated the attention and wanted to be left alone. Now the story was out, this seemed unlikely. So, rejected by society, isolated and depressed, Michael fled to India and eventually ended up in a Tibetan monastery, where he became a monk. He devoted the rest of his life to Buddhism and writing. Despite the prejudice he had encountered, he later wrote how he owed his life and happiness to Sir Harold Gillies.

When Gillies died in 1960 reconstructive surgery still relied on the tube pedicle. But the pedicle – even the waltzing pedicle – had its drawbacks. As it needed to be kept attached to its blood supply, moving tissue around the body took weeks. Patients had to endure straps or contraptions similar to those developed by Tagliacozzi to keep the pedicles in place, and suffer the awkwardness (and embarrassment) of having loops of flesh dangling around their bodies. There had to be a better way. Finally, by the 1970s, surgeons had come up with a solution: the operating microscope.

Today surgeons can take tissue from anywhere on the body. They use a large microscope positioned over the operating table to connect together minute blood vessels less than two millimetres across. Once the microscope is swung into place, they employ impossibly small needles and minute threads, narrower than a human hair, to make tiny, precise stitches. When Chinese surgeons first attempted microsurgery forty years ago, they unpicked a pair of stockings and used the fine nylon thread. Microsurgery is the same technology that made Clint Hallam's hand transplant possible (see Chapter 3).

What Gillies and McIndoe did not realize is that the transplanted tissue needs only a single artery and single vein to keep it alive. So even a relatively large swathe of tissue – skin, bone and muscle – taken from, for instance, the leg can be grafted on to a patient's face as long as it is connected by two blood vessels. Rebuilding a patient's jaw can be done in a single operation rather than over a period of months. Operating under the microscope has revolutionized reconstructive surgery and consigned the tube pedicle to history, although pedicles are still occasionally employed when all else fails.

But even the technology of microsurgery has its limits. As any before-and-after images of reconstructive facial surgery show, there is still a fundamental problem in repairing a face with tissue from other parts of the body. The difficulty is that the skin always looks like the area it has come from. The skin of an arm is different from the skin of a face – it can be darker or hairier – and when it is moved around the body this is all too apparent. Some surgeons believe the only solution is to transplant the skin from someone else's face.

In 2005 thirty-eight-year-old Isabelle Dinoire received a partial face transplant after being severely mauled by a dog. It was an incredible technical achievement for the French surgical team who carried out the operation, and now some surgeons are planning another huge step forward. They want to abandon traditional reconstructive surgery altogether and carry out a full face transplant. For some victims of facial disfigurement, this might be their only hope.

The story of Jacqueline Saburido illustrates the point. The bright, pretty twenty-year-old Venezuelan had moved to Austin, Texas, to study English. On the night of 18 September 1999 she was on her way home from a party, sitting in the front passenger seat of a car being driven by another student; three other friends were in the back. It was four in the morning, the road was dark. Suddenly an SUV veered across the carriageway towards them. Its driver was drunk.

When paramedics reached the scene, the front of the car Jacqui was travelling in was crumpled, the engine ablaze, broken glass across the road. The driver was dead – crushed by the steering wheel. One of the back seat passengers was also dead. The other two were pulled free, but Jacqui was pinned into her seat by the dashboard. She screamed for help as the flames reached higher. The paramedics tried to put out the fire but could do nothing to free her.

Then the screaming stopped.

When the firefighters arrived they doused the flames. Jacqui's flesh steamed as they gently turned the water on her body. Her seat had melted, the car interior was blackened by fire. Everyone looking at this awful scene of destruction assumed she was dead. It was a relief really, the screaming had been unbearable. Then Jacqui moved. She was still alive.

Almost two-thirds of her body was severely burnt. Her face was almost completely destroyed, her hair incinerated, her skin cracked and charred. Her hands had disintegrated into stumps, and she had several fractured bones. No one expected her to live for long. The driver of the SUV walked away from the crash, although he was later convicted and imprisoned for drink-driving.

With round-the-clock care in a specialist burns unit, Jacqui gradually started to recover. Since September 1999 she has undergone more than fifty operations. Surgeons have done their best to rebuild her face; they even managed to restore an eyelid that had melted in the blaze. But now they've reached the limits of traditional reconstructive surgery and there is little more they can do. Jacqui's face remains terribly disfigured. Her features are crumpled, her neck sagging, her skin a blotchy, crinkled patchwork. She has no hair, eyebrows or lashes. Her nose is flattened and distorted, her nostrils drawn upwards. She has only the remains of a single ear, and her left eye is swollen. Jacqui is still recovering from the events of 1999 and has devoted her life to campaigning against drink-driving.

After examining cases like Jacqui's, plastic surgeons such as Peter Butler believe that face transplants are the only way forward. Butler is one of Britain's top plastic surgeons and uses imaging techniques to simulate the effects of a face swap. On a computer screen his team can virtually place one face over another. In theory, the technical problems of a face transplant have already been overcome. The surgery is perfectly possible, although the cocktail of drugs to prevent rejection would probably take ten years off a patient's life. However, there are big ethical questions over whether it is right to take the face of one person and transplant it on to another. Our faces define us – how would a new face change us? And what about the donor family – how would they react to seeing the face of a loved one on somebody else's body?

Plastic surgery has come a long way since the brutal operations conducted in early India, or Tagliacozzi's leather corset and pedicle. The real triumph of plastic surgery has not been the cosmetic surgery for the 'beauty cranks' – the botox, the silicone or the facelifts – but the effort that has gone into fixing terribly damaged faces.

Over the centuries surgery has restored the faces of syphilis victims, soldiers, airmen and the victims of fire or car crashes. Today surgeons can save the lives of even the most badly burnt and injured patients, such as Jacqueline Saburido, but despite all the advances in modern medicine they can only do so much.

Soon (possibly by the time this book is published) someone in the world will have received the first full-face transplant. You can bet the story will be a sensation. However, advances in tissue engineering will eventually enable surgeons to grow swathes of skin in the lab. They have already been able to grow a human ear on the back of a mouse. One day it might even be possible to construct an entire new face from samples of a patient's own DNA. We can only hope that the technology is used to reconstruct the faces of the victims of conflict or tragedy rather than to boost the vanity of ageing Hollywood stars, Page 3 models or the Gladys Deacons of this world.

Tagliacozzi's 16th-century jacket-and-strap arrangement. You can see the pedicle linking the patient's upper arm and face.

Rebuilding the face of William Spreckley during the First World War. The second picture shows the arrowshaped piece of cartilage implanted under the skin of Spreckley's forehead. Looking at the final picture, it is hard to believe that Spreckley was once without a nose.

Drawing of an early 19th-century operation for 'restoring' the nose. Although crude, these procedures were often successful.

Four members of the Guinea Pig Club in their ward at East Grinstead in the 1940s. They are all sporting tube pedicles showing the intermediate stages of facial reconstruction.

An 1850 interpretation of the passage of the tamping iron through Phineas Gage's skull.

A mask made of Phineas Gage's face (probably when he was still alive) pictured next to the railroad worker's skull. The partially healed hole can be seen clearly on the top.

Another day at the office for lobotomist Walter Freeman as he performs his procedure in front of a fascinated audience. This picture dates from 1949, before lobotomies became completely discredited.

Harvey Cushing, the brilliant, god-like surgeon who was adored by his patients.

Harvey Cushing operating on his 2000th brain tumour in 1931. During his impressive career, Cushing would save hundreds of lives and transform brain surgery.

A modern operation for the treatment of Parkinson's disease. The fearsome looking clamp is to hold the patient's head in place so that surgeons can place implants precisely in the affected area of the brain.