Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1399e1400

LETTER FROM AMERICA

Gillies 2.0dsenses and Sherlock Holmes

The latest iteration in the Sherlock Holmes movies arrivedin America on Christmas Day. Digital effects allowed itsdirector, Guy Ritchie, to have slow motion sequences thatshowed how Holmes used his senses to deduce facts aboutother characters. Holmes was a fictional detective, but weplastic surgeons are fortunate to have been taught Gillies’principle ‘Observation is the basis of surgical diagnosis.’1

This was Gillies’ first principle and the basis of his others.He believed that without a proper diagnosis surgicaldisaster loomed and went so far as to say, ‘Mistakes indiagnosis due to inadequate examination are perhaps thecommonest cause of indifferent treatment’.2

Gillies’ observations were limited by what he could seewith the naked eye and the occasional radiograph. When hefirst stressed the importance of accurate diagnoses almosta century ago, he enhanced his abilities of observation byhaving casts made of his patients to determine the degreeof tissue loss. Now our technical toolbox contains moreacronyms than a government bureaucracy including CT,CTA, DUS, EDS, EMG, MRI, MRA, NCS, and NIRS to name buta few. Sadly, the plastic neophyte’s infatuation with hightech toys can reach a level of almost religious fervor andfrequently is coupled with a disdain for and even aban-donment of ‘old fashioned’ clinical judgment. Sometimesscientific tools are useful, but part of the art of plasticsurgery is learning what tools to use, when to use them andhow reliable they are. Rather than abandoning clinicaljudgment, we should strive to enhance it by being likeSherlock Holmes and bring all five senses to beardseeing,hearing, touching, smelling, and tasting.

In bringing these senses to bear it is important todistinguish between the physical use of the sense and theinterpretation of the sensory input. Observation is notjust looking. Because ours is a visual specialty, weprobably are best in our ability to interpret sensoryinputs. Although there are times that we want to exploitthe fact that the eye can be fooled, such as ouremploying subunits in nasal reconstruction, we musttread carefully when failure to acknowledge that oureyes can be deceived can effect our treatment. Forexample, probably the most common mistake that the

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neophyte plastic trainee makes is to plan a procedure asif he were reading a non-topographic map and confuse airdistance with ground distance. The resulting reconstruc-tion lacks sufficient tissue because he measured frompoint A to point B on a one dimensional line rather ona two dimensional surface, thus the flap’s tip either failsto reach or is sutured with too much tension, or thenerve graft that was harvested before the joints werecompletely extended is either too short or is approxi-mated with too much tension. Other examples of the eyebeing fooled were described in 1976 by Acland in his briefbut seminal paper on misperceiving flap viability due tocolour fatigue and lighting conditions.3

How can we improve our hearing? I am not advocatinga duplex ultrasound iPhone app that we can take to hospitaland office. Rather I think that we can improve our care bylistening for characteristic sounds. Millard taught that whendoing a lateral nasal osteotomy there was a change in pitchwhen the osteotome struck the nasal process of the frontalbone. Learning to listen for that sound lessened the possi-bility of getting a bone spike with infracturing. Millardundermined his facelift flaps with a #10 blade. Although hesaid that he was relying upon his sense of touch, I alwaysheard a characteristic gritty sound when his scalpel devel-oped the correct plane. Learning to listen should not belimited to the theatre. Listening to the patient can beequally valuable in deciding what is the patient’s diagnosis,whether to operate, when to operate and what operationto do.

Touching is another sense that can be refined. Most of ushave learned that we can feel small spicules and dorsalirregularities by wetting our gloves and rubbing the dorsumduring a closed rhinoplasty. We also have learned that wecan feel if our fracture reductions are adequate bypalpating the dorsal aspect of phalanges, metacarpals andeven the distal radius. Yet our ability to feel can extendfurther. Narakas claimed that with experience one couldpalpate intraneural scarring with microforceps, and I havelearned the hard way that the increased resistance that Ifelt when doing a microanastomosis was my snagging theintima of a back wall. Yet there is more to touching than

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

1400 Letter from America

what can be gleaned with our Merkel disks and Meissner’scorpuscles. We are better physicians if we become moreempathetic and feel for our patients. I would argue that ifwe cannot empathize for our patients, then we should notbe treating them unless there are exigent circumstances.

Smelling is another sense that has been used by gener-ations of surgeons to diagnose wound infections and oursense of smell may be sufficiently sensitive that it allowsour clinical judgment to supplant quantitative bacteri-ology.4 Just as we use our noses clinically, so too we can useour noses in the Holmesian sense to question the veracity ofa situation e to ask if it passes the ‘smell test’.5 Someexamples include: Does the scientific presentation that wehave witnessed seem too good to be true? Does the paperthat we have just read have esults that seem improbable?Does the patient’s history make sense?

Last, but not least, we come to taste. Taste is notsomething that plastic surgeons do with their tongues e atleast not to our patients! Taste is the most difficult sense toperceive and some would say the most difficult one to teachor learn. Taste is the foundation of our goals in well-executed aesthetic and reconstructive surgery. There ismore to taste than that ascribed by Thompson to LeMesu-rier who evaluated his late cleft lips results with Booleanlogic, ‘. as either ‘pretty’ or not ‘pretty’ e There werenever gradations’.6 The best means of learning about tastethat I can recommend is Millard’s eighth principle ‘Knowthe ideal beautiful normal’. He devoted an entire chapterto this in his final plastic surgery book and, without notingit, included photos of his wife and children among theexamples of the ideal normal.7

Centuries ago Isaiah warned:

‘You will be ever hearing, but never understanding; youwill be ever seeing, but never perceiving.’8

Hopefully, we plastic surgeons will heed Isaiah and, likeSherlock Holmes, strive to not only enhance our senses butalso our powers of perception. We should not only look, butalso observe. We should not only hear, but also listen. Weshould not only touch, but also feel. We should not onlysmell, but also question. Finally, we should not only taste,but also opine.

References

1. Gillies HD, Millard DR. The principles and art of plastic surgery.Boston: Little, Brown; 1957. p. 49.

2. Gillies HD. Plastic surgery of the face. London: Henry Froude;1920. p. 4.

3. Acland RD. A method of eliminating errors in the perception ofskin colour. Brit J Plast Surg 1976;29:97.

4. Freshwater MF, Su CT. Potential pitfalls of quantitative burnwound biopsy cultures. Ann Plast Surg 1980;4:216.

5. http://www.wordspy.com/words/smelltest.asp [accessed 20.2.2010 ].

6. Millard DR. Cleft craft the evolution of its surgery. Boston:Little, Brown; 1976. p. 132.

7. Millard DR. Principlization of plastic surgery. Boston: Little,Brown; 1986. pp. 78e112.

8. Isaiah 6:9, http://www.biblegateway.com/passage/?searchZIsaiahþ6%3A9-10&versionZNIV [accessed 20.2.2010].

M. Felix FreshwaterUniversity of Miami School of Medicine,

9100 S Dadeland Blvd Ste 502Miami, FL 33156-7815

United StatesE-mail address: m.felixfreshwater@gmail.com