Our History

Our History

A HISTORICAL RECOUNT OF THE DIVISION OF PLASTIC AND RECONSTRUCTIVE SURGERY AT UNIVERSITY OF MIAMI AND JACKSON MEMORIAL HOSPITAL

Yash J. Avashia, BS, Steven Ovadia, BA, Seth R. Thaller, MD, DMD, FACS

“The fruits derived from labor are the sweetest of all pleasures.”
— Luc de Clapiers, Marquis de Vauvenargues

Introduction

The University of Miami Division of Plastic, Aesthetic and Reconstructive Surgery (UM-PRS) remains closely associated with pioneering surgeons and educators in the field of plastic surgery. Since its inception in 1964, the Division has helped define the field of plastic surgery in both Miami and the United States with landmark publications and training generations of contributing plastic surgeons. Nurtured by dedication and passion, the Division has reached its momentous 50th Anniversary. Over its nearly half century history, the Division has continued to grow and progress.

Central purpose of establishing the Division was to encourage formal intellectual thought in reconstructive and plastic surgery for the management of patients and training of residents. [1] The first-hand experience of past and present faculty and residents cumulatively recounts the Division’s history. The passing of our second chief, Dr. D. Ralph Millard, Jr., on June 19, 2011 has given our history a special significance. He definitely left a resounding legacy behind. Ultimately, the Division’s most substantial contribution has been the collective improvement in quality of life for the tens of thousands of patients treated by the plastic surgeons of UM-PRS throughout the past decades of its existence.

Early Plastic Surgery in Miami – 1930s through 1950s

Early names included Thomas Otto, Robert Dickey, and George Robertson. The list later grew to include Thomas Zaydon, Sr., Ralph Millard, Jr., Clifford Snyder, and Thomas Baker. Drs. Otto and Dickey were associates known to operate on cleft lips, palates and noses. As one of the early practitioners of plastic surgery in Miami, Dr. Otto’s work had been noticed by well-regarded names in American plastic surgery including Drs. John Staige Davis and Robert Ivy. [2] In the late 1940s, Dr. Otto served as a service chief for Jackson Memorial Hospital. With the University of Miami School of Medicine (UMSM) commencing in 1952, expansion of its individual departments was taking place by the early 1960s. As chairman of UMSM Department of Surgery, Dr. Dean Warren saw the need for formal plastic surgical training (Figure 1).

The decision was taken to begin developing a division of plastic surgery in 1963, with Dr. Gilbert B. Snyder appointed as the first formal chief (Figure 2). [1] Graduating from Johns Hopkins (JH) as plastic surgery chief resident, Dr. Snyder was an assiduous, young surgeon. His training at JH under plastic surgery chairman, Dr. Milton Edgerton, provided him the foundation and experience that allowed him to assume this daunting role as chief. Because only one resident was accepted into the program every other year, Dr. Snyder was responsible for all cosmetic, congenital deformity, hand, and head and neck surgery, as well as maxillofacial tumor and reconstructive surgery at JH. Around that time, Dr. Frank Gerow and Dr. Thomas Cronin from Texas introduced the first silicone breast implant [3]. Incidentally, Dr. Snyder received ample opportunity to become familiar with breast reconstruction procedures using these newly developed implants during his training.

Within two years of groundbreaking work, the plastic surgery division received accreditation from the American Board of Plastic Surgery. [1] Drawing from elements of his own training, Dr. Snyder built a program that would provide residents a strong foundation in plastic surgery. In addition to his position as division chief, he was also named chairman of the hand clinic, emergency room clinic, and head and neck cancer center. Dr. Snyder ensured that the plastic surgery division, and its residents, played an appropriate role in providing care to patients in each of these clinics. His role heading these clinics enabled him to ensure that the residents received a well-rounded and diverse education while training at UM-PRS.

In 1965, the same year the first resident, Peter Stokely, began training at the UM-PRS, a momentous dinner meeting was held at JMH for all local Miami plastic surgeons. At the meeting, voluntary faculty positions were offered to attendees. As voluntary faculty members, the surgeons gave monthly lectures on various topics in plastic surgery to the medical students and residents of UM. Another fortuitous outcome of the meeting was creation of the Miami Society of Plastic Surgeons (MSPS). [1,4] Dr. Thomas Zaydon, Sr., former resident under Dr. James Barrett Brown and founder of the first skin bank at Jackson Memorial Hospital, [24] became the first president of the group (Figure 3). In his words, “The MSPS was created to encourage organization of local plastic surgeons and to exercise the need to develop better rapport among the surgeons.” [4] During that time, plastic surgery was “tabooed.” [4] Operating room windows would be draped so other surgeons could not see the “secrets of plastic surgeons.” [1,4] Strength of relationships created from the original plastic surgeons in Miami still resonates today, as the MSPS remains one of the largest local plastic surgery societies.

The Era of D. Ralph Millard, Jr.

In 1967, Dr. D. Ralph Millard with his unique and deserving qualifications became the chief of plastic surgery at UM-PSR (Figure 4). He received a medical degree from Harvard College in 1944. Prior to arriving in Miami, he trained over a 12 year period with our century’s most renowned plastic surgeons. [5] During this time, Dr. Millard also served as chief plastic surgeon for The U.S. Marine Corps at the MASH unit in Korea. This time defined his monumental contribution to cleft lip repair. [6] His eclectic training provided him the knowledge, experience, and resources that enabled him to make enduring contributions to the division, and the entire global field of plastic surgery.

In 1957, a year after Dr. Millard began practicing in Miami, The Principles and Art in Plastic Surgery was published. Dr. Millard had spent the years of 1952 and 1953 in London writing this monumental book with Sir Harold Delf Gillies. [7] As an expansion of Dr. Gillie’s original ten commandments, the book outlines sixteen essential principles applicable to various aspects of plastic surgery. The principles also share a fundamental similarity to important philosophies of life. The novel idea of approaching plastic surgery with “principles” added to the book’s significance in the history of plastic surgery. Three decades later, in 1987, Dr. Millard published Principlization of Plastic Surgery. Through this new book, Dr. Millard expanded the sixteen essential principles with the addition of twenty new principles, for a total of thirty-three principles.

In the context of the UM-PRS and Dr. Millard, principle #30 has special significance:

“Teaching our specialty is its best legacy.”

This principle describes Dr. Millard’s philosophy on plastic surgery resident training. He placed a special importance on how students were selected for the training program. He emphasized attributes relevant and essential for the actual training. Dr. Millard believed that residents were to be chosen not only for high grades and unique talents, but also moral character, ethics, judgment, and an understanding of the “importance of integrity and necessity of persistence.” For resident applicants, the interview process at the UM-PRS was both rigorous and formidable. [8] Resident applicants were invited to visit the plastic surgery unit for three days. Character, talent, and motivation were observed. Extracurricular activities, including organized sports participation and athletic ability were also noted to assess physical stamina and mental rigor. Applicants were expected to assist throughout the three days. Also they had to withstand a continuous barrage of questions. These might occur in the operating room, the resident lounge, or even while eating lunch. In the words of Dr. Millard, they were under continuous evaluation like a “fly under a glass.”

The plastic surgery residency program was built with a gradient of responsibility for patient care and teaching. Junior residents assisted the six attending surgeons for eight months and then rotated through the hand surgery service with Dr. William Burkhalter, Professor of Orthopedics. During their training, residents had the opportunity to rotate through other services: Craniofacial Surgery (Dr. Anthony Wolfe), Breast Reconstruction (Dr. Walter Mullin), Microsurgery (Dr. John Cassel), Hand Surgery (Dr. Steven Cooley, Dr. William Burkhalter, Dr. Felix Freshwater), and VA Service (Dr. John Devine).

After completing their own formal training, Drs. Wolfe and Mullin joined Dr. Millard in practice. It was commonplace for patients to have to wait for up to 9 months to receive cosmetic consultation and an additional year for the operation by Dr. Millard. [9] Between 1974 and 1976, Dr. William Little and Dr. Walter Mullin founded the JMH Resident Cosmetic Clinic. [10] With Dr. Millard performing the majority of cosmetic procedures for his patients, residents would receive substantial observational experience but little practical experience performing cosmetic surgery. This cosmetic clinic, which deposited profits into an account dedicated towards resident education, enabled residents to receive a new level of experience with cosmetic procedures. The clinic resulted in an enormous demand and clinical experience. This in turn provided the residents with an unparalleled education. [10] At the resident cosmetic clinic, a rhinoplasty cost around $250, bilateral breast augmentations, including McGhan implants, cost roughly $500, and face and neck lifts with bilateral upper and lower blepharoplasties cost only around $750. [9] Demand for the cosmetic clinic was astounding. Patients eagerly sought the lower priced cosmetic procedures performed by the “trained residents of Millard.” [9]

The JMH Resident Clinic was also located at Memorial Hall. There were also general plastic consultations in the clinic. Certain cases were selected to be presented at the weekly grand rounds. Plastic Surgery Grand Rounds at JMH between the 1970s and early 1990s were unique. Individual patients were brought to the Grand Rounds and examined in person with discussion ensuing about the best possible treatment plan. Faculty and residents from other services would attend grand rounds to present patients requiring reconstructive surgery. Grand Rounds encouraged “cross-pollination” with other specialties presenting cases for plastic surgery service. [8]

In retrospect, it may be safe to claim that Dr. Millard and his trained residents are an appropriate example of the phrase “excellence breeds excellence.” His creative atmosphere certainly had an intangible effect on his residents. It was the concepts behind many of his innovative ideas that intrigued the residents. [11] Among the most notable experiences the residents received was the opportunity to participate in Dr. Millard’s historic work of developing the art and science of plastic surgery. In the midst of writing his three-volume encyclopedia of cleft lip and palate surgery, Cleft Craft, Dr. Millard would invite passing residents to perform some of the basic science or anatomic research in support of his epic publication. Dr. Frank Welsh, a past Maytag Fellow, [21] described his memorable assignment of performing dissection of the hard palate and supporting bone to determine an interosseous blood supply for the flaps used to reconstruct clefts. [11] Upon finding this artery, he wrote, “it won me a place in Cleft Craft.” [11]

Serving as senior vice president of medical affairs and Dean of the University of Miami School of Medicine until 1995, Dr. Bernard Fogel received reports from the department of surgery regarding all its divisions, including plastic surgery. Dean Fogel describes the relationship of Dr. Millard and the medical school as “unique”. Dr. Millard was one of very few chiefs to be allowed to maintain a private practice outside the administrative confines of the University. [12] The University made exception for Dr. Millard because of his international reputation and importance to Jackson Memorial Hospital. Dean Fogel explained, “Everyone respected the fact that he deserved the opportunities that he was given to build up the Division of Plastic Surgery to a point where it was premier within the University, if not the U.S. and maybe the world.” [12]

Continuing History with Expansion

In 1994, a multidisciplinary committee of five members was created for evaluating applicants for the new chief of the UM-PRS. [13] Dr. Seth R. Thaller, current division chief, began his tenure with the division in 1995 (Figure 5). Dr. Millard continued to train graduate plastic surgeons as a part of his 6-month Maytag Fellowship. [22] Dr. Thaller joined the division as chief after receiving extensive multi-disciplinary training including craniofacial fellowship training at University of California Los Angeles under Dr. Henry Kawamoto. Since then, Dr. Thaller has worked to expand the UM-PRS in all relevant arenas of patient care. “With his unique background in oral and maxillofacial surgery, he has sought to promote the presence of plastic surgery in treating patients with facial trauma.” [14] He has also sought to establish proper management protocols for emergent hand surgery cases at affiliated hospitals, and stress the presence of plastic surgery in their surgical management.

Each voluntary faculty at UM-PRS has a very unique and specialized expertise which enables them to provide a high caliber education for the residents. Starting with the dinner meeting in 1965, the list of affiliated voluntary faculty has grown to over 25 plastic surgeons today. Many of whom are internationally recognized for their individual contributions to the field. A sublime example is one of the early pioneers in Miami and one of the University’s active voluntary faculty members, Dr. Thomas Baker (Figure 6).

Since the 1950s, Dr. Baker has had a prolific career and has promoted an academic respect for cosmetic surgery. In his words, his most significant contribution to the continuity of plastic surgery education is the Baker-Gordon Symposium on Cosmetic Surgery. [13] Starting in 1967, the symposium today invites internationally renowned lecturers to speak on aesthetic surgery topics including body contouring, face-lifts, and rhinoplasty. Having this venue in Miami has provided educational value to the residents of UM-PRS throughout the years. [13] As co-host for this symposium and co-editor for Plastic and Reconstructive Journal, Dr. James Stuzin, one of the division’s established assistant clinical professors since 1995.

Dr. Stuzin has provided endearing assistance in teaching residents through lectures, journal clubs, and cadaveric labs. [15] For the past 10 years, he has shared his clinical knowledge in facial anatomical arrangements and techniques by lecturing and instructing at our annual resident cadaver workshops (Figure 7). [15]

As one of the first faculty of the division, Dr. Millard was a proponent of mission work and has described his mission work in Jamaica beginning in 1959. [16] In 1980, Dr. Freshwater began taking residents to Colombia twice a year. During the mission trips, residents were lectured while performing cleft, burn, congenital hand, and microtia reconstructions. [17] Furthering the evolution of mission work at UM-PRS, in 1994, Project Medishare was founded by two faculty members at the UMSM, Drs. Green and Fournier. With the official establishment of Project Medishare Plastic Surgery Program in 2003, the UM-PRS has continued to play an integral role in providing necessary surgical treatment for numerous patients suffering from a multitude of both congenital and acquired deformities. During the past decade, the plastic surgery program has sent interdisciplinary teams consisting of plastic surgeons, nurses, residents, and medical students to various regions of Haiti. Mission trips are regularly conducted on a quarterly basis under the direction of our current chief.

The Hand Program and Fellowship

At the start of the new millennium, UM-PRS established an official hand fellowship, through which a resident has been trained every year since its formation. However, while the official fellowship was recently established, the hand program’s history dates back to the 1970’s. At that time, residents of the UM-PRS received training in hand surgery working alongside plastic surgeon Dr. Steven Cooley and orthopedic surgeon, Dr. William Burkhalter. [17] Over the decades, additional faculty would assist in training the residents in hand surgery. After completing his hand fellowship under Dr. Kleinert Kutz, Dr. Freshwater began to assist in training residents. Later, in the mid-1980’s, Dr. John Cassel began assisting as well. [23]

While UM’s plastic surgery curriculum has always maintained a focus on hand surgery, the official hand fellowship program was formed in the year 2000. [18] The fellowship was developed in response to the sheer demand and necessity. With orthopedic trauma managing the majority of hand reconstructions, plastic surgery was precluded from active interaction with trauma division. The official fellowship program was founded with Dr. Milton Armstrong as the fellowship Director and began training the first fellow, Dr. Rajeev Venugopal in 2000. In 2009, Dr. Armstrong was succeeded by Dr. Zubin Panthaki, who became the second hand-fellowship director. In 2011, under Dr. Panthanki’s guidance, the hand fellowship program received full accreditation from the Accreditation Council for Graduate Medical Education. [18]

Within the program, the residents spend ten months with the plastic surgery division hand surgery service and another two months with the Department of Orthopedics at Jackson Memorial Hospital. The program provides the residents with a very broad exposure to hand surgery by allowing them train at the various local hospitals. The residents get experience with congenital differences, general hand surgery, trauma reconstruction, secondary staged hand and upper extremity reconstruction, peripheral nerve surgery and elective surgery. Through this diverse education, the UM-PRSD hand fellowship has gained a reputation for training and preparing hand fellows for anything they might encounter in practice.

Recent History

During its recent history, in 2005, the Division of Plastic Surgery continued its development through the establishment of a formal basic sciences research laboratory. [19] The laboratory is a collaboration with the Department of Medicine and Study Group and Laboratory on Sex and Gender Differences in Health and Disease. Faculty and residents have coordinated the laboratory’s research and made excellent progress into advancing current understanding of wound healing. With divisional funding, the lab has been studying wound healing in aging patients, as well as diabetic patients, since its formation in 2005. In 2009, the lab reached an important milestone with the publication of its first research article, “Estrogen Deficiency and Tobacco Smoke Exposure Promote Matrix Metalloproteinase-13 Activation in Skin of Aging B6 Mice,” in the Annals of Plastic Surgery. (20) Through this project, the laboratory has shown important roles of both estrogen and smoking in wound healing. The laboratory has continued its research into wound healing and is currently elaborating the role of Vitamin D upon wound healing. We are now directing our energy toward the potential use of stem cell with cleft repair.

The Division, A Bunyan Tree for Generations…

The evolution of the division has been much like the bunyan tree that stands robustly today in the center of our medical campus’ research quadrangle. With its original seeds giving rise to the main trunk, new aerial roots have later descended from out stretched branches to create new trunks that push into the ground. These trunks eventually grow to a similar girth of the main trunk, albeit at a later point in time. With the main trunk representative of the division’s original pioneers, the aerial trunks may be looked upon as the generations of trained residents that have dispersed across the country to create their own roots in fertile soils, spreading the UM-PRS training throughout the United States and other parts of the world. While it has only existed for fifty years, the division has achieved remarkable successes and will undoubtedly continue to provide shade to countless patients during the next eras to come.

References

1. Snyder, Gilbert B. Personal Interview. 30 Jun. 2011.
2. Otto TO. Wound Closure Without the Use of Grafts. Ann Surg. 1947 Jun;125(6):778-86.
3. Cronin TD, Gerow FJ: Augmentation mammaplasty: A new “natural feel” prosthesis. Transactions of the Third International Congress of Plastic Surgery, Oct. 13-18, 1963, Amsterdam, The Netherlands, Excerpta Medica Foundation, 1963, pp 41-49.
4. Zaydon, Sr., TJ. Personal Interview. 16 Nov. 2011.
5. Sir Harold Delf Gillies, T.P. Kilner, Sir Archibald McIndoe, Jack Mustarde, James Barrett Brown, Louis T. Byars, Frank McDowell, Claire Straith, Sidney Baron Hardy, Thomas Dillon Cronin, Robert A. Wise, Raymond O. Brauer.
6. Transactions of the International Society of plastic surgeons. First Congress, Stockholm and Uppsala. 1955. Edited by Tord Skoog, M.D., General Secretary of the Congress, in co-operation with Robert H. Ivy, M.D., and the Editorial Board of Plastic and Reconstructive Surgery. 10 × 6½ in. Pp. 568 + xvi, with 467 illustrations. 1957. Baltimore: Williams & Wilkins Co. (London: Bailliere, Tindall & Cox).
7. Millard DR Jr. Gillies Memorial Lecture. Jousting with the first knight of plastic surgery. Br J Plast Surg. 1972 Apr;25(2):73-82.
8. McCafferty, Leo. Personal Interview. 14 Apr. 2011.
9. Freshwater MF. The best cosmetic surgery that money can buy. J Plast Reconstr Aesthet Surg. 2008 Oct;61(10):1271-2.
10. Mullin, WR. Personal Interview. 17 Jun. 2011.
11. Welsh, F. Personal Interview.
12. Fogel, B. Personal Interview. 7 Aug. 2011.
13. Baker, TJ. Personal Interview. 20 Jul. 2011.
14. Moulton-Barrett, R. Personal Interview. 25 Jul. 2011.
15. Stuzin, JM. Personal Interview. 28 Nov. 2011.
16. Millard, DR Jr. A Jamaican reconstructive surgical program. Arch Surg. 1961 Nov;83:707-18.
17. Freshwater, MF. Personal Interview. 13 Aug. 2011.
18. Panthaki, ZJ. Personal Interview. 1 Sept. 2011.
19. Elliot, SJ. Personal Interview. 30 Aug. 2011.
20. Kassira N, Glassberg MK, Jones C, Pincus DJ, Elliot SJ, Fritz JR, Karl M, Thaller S. Estrogen deficiency and tobacco smoke exposure promote matrix metalloproteinase-13 activation in skin of aging B6 mice. Ann Plast Surg. 2009 Sep;63(3):318-22.
21. Maytag Fellowship
22. Millard DR, Jr. D. Ralph Millard, Jr.: Strong, Stronger, Strongest. Plast and Recon Surg. 98(2);378, Aug 1996.
23. Cassel JM. Personal Interview.
24. B.G. News of Science. American Association for the Advancement of Science. 1955. Oct; 122:683-85