Denis F. Keegan: Forgotten pioneer of plastic surgery *

Correspondence and communications 1131 Colin A.B. Jahoda Department of Biological Sciences, University of Durham, Durham, UK Crown Copyright ª 2011 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2011.12.008 HISTORICAL NOTE Denis F. Keegan: Forgotten pioneer of plastic surgery * Historical questions Today every beginning plastic surgery trainee learns that full thickness nasal reconstructions must be lined or they will contract. But this was not always known. Originating in India over 2000 years ago, forehead flap nasal reconstruction is our specialty s oldest procedure; however, the need for lining is a relatively recent discovery. When was this principle first recognized? For centuries surgeons have been promoting procedures. When did a surgeon step back from the lectern or operating table and describe the social influences that impacted the need for surgery? Intrinsic to progress, surgeons describe how their new methods are better than others. When did a surgeon abandon his method in favour of a colleague s modification and publicly renounce his method in favour of another? Answers in India This is the story of Denis Francis Keegan, a forgotten pioneer of nasal reconstruction. Most biographical information about Keegan is from records of the Indian Medical Service and his obituary, by Henry Smith, in the British Medical Journal. 1,2 Keegan was born in Ireland on December 17, 1840. He obtained his medical education at Trinity College Dublin. There he obtained B.A. and M.D. degrees. He became a M.R.C.S. on July 30, 1861, but did not become a F.R.C.S. until April 9, 1891, when he was elected with 20 years standing. Keegan joined the Indian Medical Service as an assistant surgeon on March 31, 1866 and rose through the ranks, becoming a brigade surgeon lieutenant colonel on August 11, 1891. For his final fifteen years in India, Keegan was surgeon at the Charitable Hospital in Indore where he performed his nasal reconstructions. Upon retiring from the Indian Medical Service on April 1, 1894 he left India. He died in Dublin on January 1, 1920 and was survived by a son and two daughters. Knowledge spreads to the west On February 21 1891, Keegan s paper Rhinoplasty appeared in The Lancet. 3 He described the need for and manner of lining flaps in nasal reconstruction in great detail and with descriptive line drawings. Three parts of the paper are noteworthy. First, he began his paper with a sociological focus by making the insightful observation of the reason for a dearth of nasal reconstruction in the West: In Europe, in the majority of cases, rhinoplasty is performed in order to repair the ravages and disfigurement caused by lupus or tertiary syphilis, and it is but seldom that plastic surgery is called upon to make good the damage done to a nose by accident or mutilation. In India, on the other hand, in the vast majority of cases, rhinoplasty is performed to hide the ghastly disbursement caused by mutilation, and our patients are almost all invariably young, healthy and robust. Second, although the concept of lining flaps had not been described beforehand, Keegan renounced all claims of originality e a degree of modesty that remains rare even now: This method of forming new noses has been worked out independently by my assistant, Mr. Gunput Singh, and myself, but we disclaim for it any title to originality, for he would be bold indeed who would assert that he had devised a perfectly new operation in the changeful field of plastic surgery. Third, he documented his results by including before and after images of some of his patients: Appended are eight engravings, taken from photographs of four patients out of a large number on whom I operated during the past three years at Indore. They speak for themselves, and show plainly how much plastic surgical art can relieve the ghastly disfigurement caused by the ruthless knife of the mutilator. Knowledge of Keegan s method spread beyond The Lancet. By September 1891, a synopsis of his paper, without the engravings, had been published in the United States in the Annals of Surgery. 4 Also that year, Sir Fredrick Treves A Manual of Operative Surgery, was published both in England and America, and its rhinoplasty chapter included engravings of Keegan s third case. Treves effusively wrote: Among the most excellent results obtained by rhinoplasty must be placed the very admirable series of cases published by Surgeon-Major Keegan in the Lancet for Feb. 21, 1891. 5 The missing lecture In 1895 Keegan lectured to the Surgical Section of the British Medical Association in London. A summary, without the accompanying photographs, was published in the October 12, 1895 issue of the British Medical Journal. a Keegan wrote: * Meeting Information: Presented in part as an e-poster at the 16th Congress of the International Confederation of Plastic Reconstructive and Aesthetic Surgery, Vancouver May 2011. a Although the paper is missing from the Surgeon-General s Index and the Leuz Index, Keegan referred to it in his 1900 monograph.

1132 Correspondence and communications The skin and tissues clothing the nasal bones are dissected from off their bed, and the dissection is made from above downwards; The skin and tissues thus raised from their bed are reflected downwards, and therefore the skin of this nasal flap [emphasis added] looks backwards and its raw surface forwards. A flap is now raised from the forehead, and is brought down and placed on the nasal bones and on the raw surface of the flap [emphasis added] taken from off the nasal bones. It therefore follows that the inside of the newly formed nose is lined with skin, and this lining prevents any subsequent contraction. 6 Why had Keegan described two dorsal flaps that were transposed to create lining in The Lancet, yet here Keegan described only a single flap? Was this a typographical error? An alternative answer is that despite having left India that Keegan communicated with his close friend and colleague Henry Smith. Two years later, on October 23, 1897, Surgeon-Captain Henry Smith of the Indian Medical Service had his Notes of Surgical Cases at the Jullundur Civil Hospital in Punjab published in the British Medical Journal. b Smith wrote, Keegan s flaps are about as perfect as they can be, except that neither Keegan, nor anyone else that I am aware of, makes any provision for a new septum. 7 To remedy this, Smith described how he transposed all dorsal nasal skin as a single flap rather than two flaps as Keegan had devised. Keegan s monograph In 1899, Keegan completed his monograph On Rhinoplastic Operations that was published in London a few months later. 8 (Figure 1) It was not a pure exposition of surgical technique. Rather like Carpue in the early 19th century, Keegan reviewed the progress that had been made in rhinoplasty until his time even including mention of Joseph s open rhinoplasty and Weir s closed method. There are several striking features about Keegan s book: Never before had the root causes of the need for plastic surgery been described. Yes, prior authors had mentioned the purported aetiology of their patients conditions, e.g., a sword or syphilis, but Keegan describes the sociology of nasal loss and contrasted his wealth of clinical cases amongst the poor of India with the dearth of cases in Europe. He noted that the patients in India universally had traumatic deformities that in women were due to spousal abuse: In fact the great majority of the victims are women who have incurred the jealousy of their husbands, for in India, there is no divorce court for the native population, and among the lower orders a man who suspects his wife sometimes cuts off her nose, afterwards turning her adrift. Of course the husband s suspicions are, not always well founded, and the unhappy wife, mutilated without reason, is condemned to lifelong sorrow and degradation. For nose cutting b Smith s inventive mind is revealed by descriptions of constant irrigation system to clear away blood during head and neck surgery, the use of horsehair sutures rather than gut, and the invention a series of urethral dilating catheters. the Indian penal code awards the punishment of imprisonment for a period from one or two years to seven, according to circumstances. Public opinion is generally on the side of the husband, and in Native States the punishment is usually much less - perhaps about six months imprisonment. 9 One can appreciate Keegan s empathy for his patients when he wrote that: In the East a women who has lost her nose is regarded as unchaste, is looked down on by her neighbours, and is an object of ridicule when she leaves the house, as for instance when she goes to the well to draw water. One may therefore imagine the lifelong misery entailed on an unfortunate wife, perhaps entirely guiltless, who has been the subject of mutilation, and it is easy to understand how great a boon to them a well-performed rhinoplasty must be. 10 Keegan performed between 40 and 50 nasal reconstructions and illustrated his book with 21 photographs (Figure. 2). Keegan precisely described how he aimed to accurately document his results: The illustrations are. reproduced photographically from the original cabinet photographs. As there has been no retouching of the original photographs, or the half tone blocks, the illustrations faithfully represent the appearance of the patients. 10 More questions and possible answers Why has Keegan been forgotten? Five potential reasons exist: Scarcity of cases As Keegan himself noted, nasal reconstruction was relatively rarely needed in the West where the few cases of nasal loss were caused by syphilis or skin cancer. This was distinct from India where, as Keegan described in detail, most cases were post-traumatic. Not until World War I would there be an unfortunate plethora of post-traumatic clinical cases in the West. Scarcity of Keegan s book Keegan s book was difficult to obtain. Even now, only 19 copies are known to exist. Worldcat.org lists 18 and I own one (Table 1). Gillies independent discovery of lining flaps In 1957, Gillies described how he made the same discovery independently. Gillies described his experience of trial, error, observation and conclusion thusly 11 : It had been taught that all flap noses inevitably shrank at least 30 per cent, so flaps were cut generously large, yet never large enough.. Despite similar efforts, too

Correspondence and communications 1133 Figure 1 Title page of On Rhinoplastic Operations with a Description of Improvements of the Indian Method. many of our noses shrivelled [sic] to a cauliflower. Then Private Day was admitted with three-quarters of his nose missing. A couple of convenient turbinates were turned up for support and covered with a generous forehead flap. The usual group gathered about the patient on the second postoperative day and swelled to a larger crowd after the first week, for the new nose was not shrinking. We were all certain this was merely a delayed

1134 Correspondence and communications Figure 2 Composite pre- and post-op photographs of some of Keegan s patients. From On Rhinoplastic Operations with a Description of Improvements of the Indian Method. London: Ballière, Tindall and Cox; 1900: 20-43.

Correspondence and communications 1135 Table 1 Extant copies of Keegan s book and their locations (Source: www.worldcat.org). Institution National Library of Medicine Countway Library, Harvard Cushing-Whitney Library, Yale Webster Library, Columbia University New York Academy of Medicine College of Physicians Philadelphia Jefferson Medical College Medical College of Wisconsin National Library of Scotland University of Glasgow Royal College of Surgeons of England Wellcome Institute British Library Oxford University Cambridge University University of Otago Monash University Benedict XVI Medical Library, University of Notre Dame Personal copy Location Bethsda MD Boston MA New Haven CT New York NY New York NY Philadelphia PA Philadelphia PA Milwaukee WI Edinburgh Glasgow London London London Oxford Cambridge UK Dunedin NZ Melbourne AU Sydney AU Miami FL contraction; I could not bring myself to reduce the nose for some time, and even then it took me several stages. The turbinates had served as lining to prevent contraction, but not realising this principle I cut the next forehead flap slightly smaller, and without lining it had soon shrunk to nothing. At last I tumbled to the trouble, and by religiously providing lining to our flaps thereafter we checked contraction, which enabled us to cut our flaps to exact size and effect a tailored result. It was after this that I came on the remarkable work from India of Keegan, who had been providing exact inturned flaps for lining to the tip and alae. His particular flaps were applicable only to the loss of the lower third or fleshy part of the nose, as seen in the Indian type of mutilation, but the principle was soon extended and modified until all types of losses could be successfully restored. Indeed, Gillies had credited Keegan for discovering the importance of lining flaps in his 1920 book 12 : The author had recognised that all noses must be skinlines, but on digesting Keegan s written work one was absolutely convinced that this is the right principle. Difficulty for others to duplicate Keegan s results The hallmark of any scientific discovery is its duplication by others. John Staige Davis, whose plastic surgery textbook became the bible for a generation of general surgeons attempting plastic surgery, honestly depicted his own patients. Some of Davis s results were at best mediocre. This is not a reflection on the unsoundness of Keegan s design, but is a reflection on Davis execution. 13 (Figures 3 and 4) For unknown reasons, Davis decided to graft the forehead donor site. The production of mediocre results would continue for at least another half century with the ironic result that forehead flap nasal reconstruction was frowned upon in the U.S. Army. As Millard noted: Although an army edict was not issued, at least a precedent was set against forehead flaps by army plastic surgeons. 14 Keegan s modesty Keegan was extremely modest; he even stated that Smith s modification was superior to his own technique: For another and a better method of utilizing these nasal flaps, see p.63 for the description of the operation devised by Captain Henry Smith. 15 I have on two recent occasions performed Captain Smith s operation on the cadaver, and am of opinion that Figure 3 Pre- and 5 day post-op photographs of JS Davis post-luetic nasal reconstruction. From Plastic Surgery Its Principles and Practice. Philadelphia: P. Blackiston s Sons, 1919: 457 figure 493.

1136 Correspondence and communications Figure 4 Left 2 images are 3 month and right 2 images are 6-month post-op photographs of the same patient as Figure 3. From Davis JS. Plastic Surgery Its Principles and Practice. Philadelphia: P. Blackiston s Sons, 1919: 457 figure 494. his method of dealing with the flaps raised from the nasal bones is an improvement on my operation, and I would strongly advise its adoption. That it never struck me to try his method, considering the many opportunities I had of doing so, shows how near one may be to a discovery and yet miss it. 16 Further proof of Keegan s modesty can be found in Keegan s obituary, when Smith wrote that, The Government of India did not do themselves [sic] the honour of honouring him with a decoration. Smith, who arrived in India in 1890, would not have known that in 1880 Keegan was awarded the Kabul-Kandahar Bronze Star for service during the Second Afghan War unless Keegan or another person had told him. 17,18 Perhaps this quote from Robert Burns that Smith used in Keegan s obituary offers a clue as to the reason for Keegan s modesty: He had too much pride for servility and too little prudence for selfishness. 19 Conclusion Keegan should be remembered for his surgical advances, his modesty and for highlighting the fact that plastic surgery is not only about technique but also about the social justifications for its necessity. Conflict of interest None. Funding None. References 1. Crawford DG. Roll of the Indian medical service 1615e1930, vol. 1. London: W. Thacker & Co.; 1930. p. 172. 2. Smith H. Obituary Denis Francis Keegan. BMJ 1920;1:380. 3. Keegan DF. Rhinoplasty. Lancet 1891;1:419e22. 4. Pilcher JE. Keegan on rhinoplasty. Ann Surg 1891;14:254e6. 5. Treves F. A manual of operative surgery, vol. 2. Philadelphia: Lea Brothers & Co.; 1892. pp. 15e38. 6. Keegan DF. On rhinoplasty in India. BMJ 1895;2:890. 7. Smith H. Notes of surgical cases at the Jullundur civil hospital in Punjab. BMJ 1897;2:1180e1. 8. Keegan DF. On rhinoplastic operations with a description of improvements of the Indian method. London: Ballière, Tindall and Cox; 1900. 9. Keegan DF. On rhinoplastic operations with a description of improvements of the Indian method. London: Ballière, Tindall and Cox; 1900. pp. 17e18. 10. Keegan DF. On rhinoplastic operations with a description of improvements of the Indian method. London: Ballière, Tindall and Cox; 1900. p. 19. 11. Gillies HD, Millard DR. The principles and art of plastic surgery, vol. 1. Boston: Little, Brown and Co; 1957. pp. 27e8. 12. Gillies HD. Plastic surgery of the face. London: Henry Frowde; 1920. p. 262. 13. Davis JS. Plastic surgery its principles and practice. Philadelphia: P. Blackiston s Sons; 1919. p. 457. 14. Millard DR. Principlization of plastic surgery. Boston: Little, Brown and Co.; 1986. p. 27. 15. Millard DR. Principlization of plastic surgery. Boston: Little, Brown and Co.; 1986. p. 61. 16. Millard DR. Principlization of plastic surgery. Boston: Little, Brown and Co.; 1986. p. 63. 17. Crawford DG. Roll of the Indian medical service 1615e1930, vol. 1. London: W. Thacker & Co.; 1930. p. 220. 18. http://www.garenewing.co.uk/angloafghanwar/waroffice/ medals.php [accessed 01.01.12]. 19. Burns R. In: Chambers Robert, editor. ThelifeandworkofRobert burns,vol.2.edinburgh:williamandrobertchambers;1851.p.57. M. Felix Freshwater Voluntary Professor of Surgery, University of Miami School of Medicine, 9100 S. Dadeland Blvd, Ste. 502, Miami, FL 33156-7815, USA E-mail addresses: mfelix.freshwater@gmail.com, mff@miami-hand.com ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.02.018