An Evidence Based and Historical Review of War Surgery of the Face and Jaws

Abstract

War surgery of the face and jaws is a fascinating and complex area of surgery and medicine with a relatively short history of formal development as a specialty despite surgical procedures being performed on this area of the body over the centuries. It was not until the mid-nineteenth century when surgery was evolving into a science rather than a trade, that literature was being published on aspects of face and jaw surgery as well as some of the innovative appliances or techniques. The First World War was the birth of the specialties of plastic and maxillofacial surgery and provided abundant clinical material for the surgical techniques and innovations that would subsequently evolve into the surgical principles taught to successive generations of surgeons including those of today.

This thesis sets out to provide a logical sequence of linkages between history, surgical principles and evidence-based medicine by way of an historical review, case studies to illustrate the surgical principles developed from war experiences and evidence-based systematic reviews of contemporary topics on face and jaw war surgery relevant to current combat operations in order to provide recommendations for military surgeons on future deployments.

The historical development of face and jaw war surgery was as much about the necessity for innovation and adaptability as it was about the skill of pioneering surgeons such as Gillies, Pickerill and McIndoe. This thesis reviews the major innovations and developments in face and jaw war surgery that came about during major conflicts starting with the First World War and continuing through to current conflicts in Afghanistan. Surgical principles identified from this historical review of war surgery of the face and jaws have been illustrated in this thesis by a series of case studies from the Pickerill Collection and archival material from the School of Dentistry, University of Otago which present surgeries performed by Pickerill and his co-workers during the First World War. Discussion on the advances in treatment since Pickerill’s time and illustrative examples of contemporary surgeries performed in Afghanistan provides a comparison between the time periods, highlighting not only the advances in medicine and science since 1918 but also aspects of surgical care that appear to have withstood the test of time.

This thesis provides the modern face and jaw surgeon with the necessary historical background and context from which current surgical principles have been developed. By way of evidence-based systematic reviews, the importance and relevance of war surgery of the face and jaws in current military medicine and surgery is highlighted for clinicians and military planners. Current operations in Afghanistan and Iraq have seen a proportional increase in combat related head, face and neck injuries due to the survival of soldiers wearing combat body armour and patterns of injuries resulting from blast fragments. This increase in incidence and the complexity of head, face and neck war surgery, emphasises the need to include surgeons with specialist expertise in this field for future operations. The importance of having an historical perspective in order to appreciate lessons learnt from past conflicts cannot be over-stated.