Plastic Surgery Principles
Plastic surgeons possess unique and versatile skills for reconstructing defects relating to cancer extirpation, cosmetically enhancing normal anatomy, salvaging limbs after trauma, rehabilitating burn patients, ameliorating childhood deformities, and performing autotransplantation as well as allotransplantation. This expertise is also called on in devising creative solutions to a variety of problems faced by physicians in other specialties, and plastic surgeons are frequently consulted by colleagues across disciplines.
Ambroise Paré (1564) — The Original Five Principles
Five broad surgical aims are traditionally attributed to the sixteenth-century surgeon Ambroise Paré, whose Dix livres de la chirurgie was published in 1564. The wording below is the English rendering commonly quoted in plastic surgery teaching.[2]
- Take away what is superfluous
- Restore to their places things which are displaced
- Separate those things which are joined together
- Join those which are separated
- Supply the defects of nature
Sir Harold Gillies — Ten Commandments Teaching Tradition
The following “ten commandments” are a teaching formulation of Gillies' principles, associated with D. Ralph Millard, who codified them around 1950. Gillies and Millard's The Principles and Art of Plastic Surgery (1957) expanded them to 16 principles.[3]
- Thou shalt make a plan
- Thou shalt have a style
- Thou shalt honor that which is normal and return it to normal position
- Thou shalt not throw away a living thing
- Thou shalt not bear false witness against thy defect
- Thou shalt treat the primary defect before worrying about the secondary one
- Thou shalt provide thyself with a lifeboat
- Thou shalt not do today what you canst put off until tomorrow
- Thou shalt not have a routine
- Thou shalt not covet thy neighbor's plastic unit, handmaidens, forehead flaps, Thiersch graft, ox cartilage nor anything that is thy neighbor's
Updated Gillies' Principles (16 Expanded Principles)
Gillies and Millard's 1957 work outlines 16 principles. The table below paraphrases them.[3]
| # | Principle | Commentary |
|---|---|---|
| 1 | Observation is the basis of surgical diagnosis | A keen sense of observation is invaluable in making an accurate diagnosis |
| 2 | Diagnose before you treat | A problem should be accurately determined before proceeding with an operation |
| 3 | Make a plan and a pattern for this plan | Preoperatively establish a goal and develop a method; intraoperative improvisation is expected but cannot substitute for a preoperative plan |
| 4 | Make a record | Accurate records assist with coordinating care and provide medicolegal protection |
| 5 | The lifeboat | Anticipate possible difficulties; devise a secondary plan in case the primary plan fails |
| 6 | A good style will get you through | Surgical style is "the expression of personality and training exhibited by the movements of the fingers" — develop a style but remain able to modify it |
| 7 | Replace what is normal in a normal position and retain it there | Surgical reconstruction requires recognizing what is normal in order to restore displaced parts to their correct place |
| 8 | Treat the primary defect first | Concern with secondary defects must not impede treatment of the primary defect |
| 9 | Losses must be replaced in kind | Like should be replaced with like (e.g., hairless skin with hairless skin); when exact replacement is unavailable, the closest substitute is used (e.g., urothelium with buccal mucosa) |
| 10 | Do something positive | When faced with a complex intraoperative problem, taking any constructive step toward the solution is vital |
| 11 | Never throw anything away | In reconstructive surgery, never discard tissue unless certain it is not needed |
| 12 | Never let routine methods become your master | Master routine methods, but remain open to advancement and innovation |
| 13 | Consult other specialists | Collaboration allows dissemination of solutions across specialties and improves patient care |
| 14 | Speed in surgery consists of not doing the same thing twice | Doing things right the first time is more efficient than correcting errors |
| 15 | The aftercare is as important as the planning | Appropriate postoperative monitoring and care is crucial — and in some cases more important than the surgery itself |
| 16 | Never do today what can honorably be put off until tomorrow | When danger or doubt is associated with a surgical maneuver, consider whether the decision may be deferred for a safer time |
Millard's 33 Commandments of Plastic Surgery
D. Ralph Millard Jr., Gillies' most celebrated trainee and the originator of the rotation-advancement repair for cleft lip, expanded these principles into 33 commandments organized across five domains:[4]
Preparational Principles
- Correct the order of priorities
- Aptitude should determine specialization
- Mobilize auxiliary capabilities
- Acknowledge your limitations so as to do no harm
- Extend your abilities to do the most good
- Seek insight into the patient's true desires
- Have a goal and a dream
- Know the ideal beautiful normal
- Be familiar with the literature
- Keep an accurate record
- Attend to physical condition and comfort of position
- Do not underestimate the enemy
Executional Principles
- Diagnose before treating
- Return what is normal to normal position and retain it there
- Tissue losses should be replaced in kind
- Reconstruct by units
- Make a plan, a pattern, and a second plan (lifeboat)
- Invoke a Scot's economy
- Use Robin Hood's tissue apportionment
- Consider the secondary donor area
- Learn to control tension
- Perfect your craftsmanship
- When in doubt, don't
Innovational Principles
- Follow up with a critical eye
- Avoid the rut of routine
- Imagination sparks innovation
- Think while down and turn a setback into a victory
- Research basic truths by laboratory experimentation
Contributional Principles
- Gain access to other specialties' problems
- Teaching our specialty is its best legacy
- Participate in reconstructive missions
Inspirational Principles
- Go for broke
- Think principles until they become instinctively automatic in your modus operandi
Modern Reconstructive Principles
The following summarizes ten fundamental principles of plastic surgery described by Kung and Chung.[6] The Gurtner and Neligan textbook provides broader reconstructive context.[1]
| Principle | Statement |
|---|---|
| I | Make an informed decision to operate or not operate |
| II | Optimize modifiable patient factors |
| III | Perform adequate debridement prior to reconstruction |
| IV | If possible, replace like with like; if not possible, create it |
| V | Optimize vascularity at every opportunity |
| VI | Preserve form and function |
| VII | Minimize donor site morbidity |
| VIII | Protect the surgical site postoperatively |
| IX | Have a backup plan (and a backup plan for that backup plan) |
| X | Innovate new solutions to old problems |
Technical Corollaries for Reconstructive Surgery
Reconstructive surgery is performed with all efforts aimed at minimizing tissue injury and promoting healing.[1]
Suture selection: Choose material, caliber and placement for the tissue, tension, healing environment and specific operation. Avoid a suture so large or tight that it compromises perfusion, but do not apply a single 4-0 to 6-0 or 3-0 to 4-0 prescription to every flap, graft or urethral anastomosis. See the dedicated sutures page for material and site-specific discussion.
Tissue mechanics: All tissue has physical characteristics that must be respected during reconstruction:[1][5]
- Extensibility. How far skin elongates under load, measured at a specified force in some tests or as strain at failure in tensile tests; it is distinct from the limit of reversible elastic deformation.[7][8]
- Inherent tension. The resting tension within unloaded tissue
- Stress relaxation. Under constant strain, tissue tension decreases over time (exploited in tissue expansion and intraoperative stretch)
- Creep. Under constant load, tissue gradually elongates over time
Dermal collagen-fibre orientation influences skin's direction-dependent mechanical response. In ex vivo pig skin, interstitial-fluid loss contributed to early stress relaxation, with related direction-dependent deformation observed in vivo in human mid-back skin.[9] Understanding and exploiting them allows surgeons to close defects that initially appear impossible. In a piglet model of 27 random-pattern flaps, increased closure tension reduced blood flow and, in flaps with impaired blood supply, was associated with more necrosis.[10]
Urethral reconstruction application. Buccal mucosa is a commonly used non-keratinizing graft with established urethral applications; whether it is suitable depends on disease, recipient bed, donor health and the reconstruction planned.[1] For urethral reconstruction, the 2026 EAU guideline weakly recommends flaps when urethral-bed vascularization is poor and strongly recommends counseling patients about potential complications of the proposed oral graft.[11]
References
1. Gurtner GC, Neligan PC, eds. Plastic Surgery. 4th ed., vol. 1: Principles. Elsevier; 2017. Publisher listing.
2. Paré A. Dix livres de la chirurgie. Paris: Jean Le Royer; 1564. Bibliothèque nationale de France catalogue.
3. Gillies H, Millard DR. The Principles and Art of Plastic Surgery. Vol. 1. Boston: Little, Brown and Company; 1957.
4. Millard DR Jr. Principlization of Plastic Surgery. Boston: Little, Brown and Company; 1986.
5. Daly MJ, Davies DM. Biomechanics of skin. In: Neligan PC, ed. Plastic Surgery. 4th ed. Vol. 1. Elsevier; 2017.
6. Kung TA, Chung KC. "Fundamental Principles of Plastic Surgery." In: Chung KC, ed. Grabb and Smith's Plastic Surgery. 8th ed. Wolters Kluwer; 2020. ISBN 9781496388247.
7. Clark JA, Cheng JC, Leung KS. "Mechanical properties of normal skin and hypertrophic scars." Burns. 1996;22(6):443–446. doi:10.1016/0305-4179(96)00038-1
8. Graham HK, McConnell JC, Limbert G, Sherratt MJ. "How stiff is skin?" Exp Dermatol. 2019;28(Suppl 1):4–9. doi:10.1111/exd.13826
9. Dwivedi KK, Lakhani P, Kumar S, Kumar N. "Effect of collagen fibre orientation on the Poisson's ratio and stress relaxation of skin: an ex vivo and in vivo study." R Soc Open Sci. 2022;9(3):211301. doi:10.1098/rsos.211301
10. Larrabee WF Jr, Holloway GA Jr, Sutton D. "Wound tension and blood flow in skin flaps." Ann Otol Rhinol Laryngol. 1984;93(2 Pt 1):112–115. doi:10.1177/000348948409300202
11. Lumen N, Campos Juanatey F, Dimitropoulos K, et al. EAU Guidelines on Urethral Strictures. EAU Guidelines Office; 2026. Tissue Transfer.