Portal de Periódicos da CAPES

D. Ralph Millard, Jr., M.D., 1919 to 2011

2012; Lippincott Williams & Wilkins; Volume: 129; Issue: 5 Linguagem: Inglês

10.1097/prs.0b013e31824a2e83

1529-4242

S. Anthony Wolfe,

History of Medical Practice

REMEMBRANCES OF TIMES PAST In 1971, I was a senior resident in general surgery at the then Peter Bent Brigham Hospital, and had decided against going into neurosurgery in favor of plastic surgery. The problem was that I knew very little about plastic surgery, because hardly any was being performed at the Brigham Hospital at that time. What knowledge I had about the specialty came from looking through textbooks in the Harvard Medical Library and leafing through issues of Plastic and Reconstructive Surgery. I found that I was finding a number of stunningly good articles by the same author on a variety of subjects, including refinements of the rotation advancement procedure, total nasal reconstruction with a forehead flap, and submental lipectomy with face lift. The author was D. Ralph Millard, Jr. Bob Bartlett, who was working in Frannie Moore's laboratory on an early version of the membrane oxygenator (a precursor of extracorporal membrane oxygenation), said that he had heard Millard speak at an American College meeting in Miami. Bob said that he was quite a showman; wearing a gold suit, he gave a talk on cleft lip in which he gave a detailed analysis of the anatomical elements of the normal lip in a young girl, and then showed that she actually had had a wide cleft, repaired so well that she appeared completely normal. I looked in the green book, which listed Accreditation Council for Graduate Medical Education–accredited plastic surgery residencies, and found nothing for Miami. I wrote to Dr. Millard, asking whether he had a residency. A letter came a few weeks later, signed by John Devine, M.D., saying that yes, there was a residency, and that I was invited down for a 3-day interview. I can remember several things from those 3 days. I came to the operating room to see Dr. Millard perform a cleft lip repair. I watched from over his left shoulder, impressed with his fluent and gentle handling of the soft tissues, and his use of the Gillies needle holder and Adson forceps, both from Stille. When he had finished, not having said a word to me during the operation, he turned slightly and said, “What did you think of that?” I answered, “That was really interesting … you did not throw anything away, and found a use for everything ….” That must have been the right answer, because the next day, in the cafeteria line, he turned my way and said out of the corner of his mouth that he had a spot for me in the residency (Millard throughout his career stayed out of the Match).Ralph Millard scrutinizing the work of a resident at grand rounds, circa 1983.Residency at that time meant that the junior resident would be taught by the senior resident, and the senior resident was on his own, without attending help. Millard would only scrub with us on a cleft lip or forehead flap, and it was difficult for him to act as an assistant. Most of his teaching came at Wednesday morning rounds, where all preoperative patients would be presented in person to the chief, who expected to see the patients postoperatively as well. He would sit inscrutably through these proceedings, always wearing his dark glasses.Inscribed photograph taken in the late 1990s.After finishing the residency in 1974, I was getting ready to go to Paris to spend a year with Paul Tessier (Millard knew Tessier, and had put a word in for me). One afternoon, in his office at 1444 NW 14th Avenue, again out of the corner of his mouth, he said, “When you finish in Paris, we need someone here to do bone work ….” So when I returned from Paris I became Ralph Millard's “bone man.” I started in 1975, and for the next 25 years, with no contract, worked with Millard and the Miami residents in his residency program at Jackson Memorial Hospital. During that period, Millard grew from an often brash but always dazzling showman with extraordinary results, to a revered and iconic figure in plastic surgery. BIOGRAPHICAL DATA David Ralph Millard was an attorney in St. Louis, and David Ralph Millard, Jr., was born at Barnes Hospital, where he would return years later to train in plastic surgery under James Barrett Brown, albeit briefly. The Millard family then moved to Asheville, North Carolina; Ralph rose to become an Eagle Scout, and graduated from the Asheville School for Boys, which of all his schools he supported the most. He went on to Yale University, where he played football until a knee injury ended his career, and was on the boxing team. He remained a passionate spectator of these two sports for life (as residents, we would go with him to watch his sons Duke and Bond play football, and we were invited as well to Angelo Dundee's gym in South Beach for boxing matches). After graduating from Yale in 1941, he went through the accelerated wartime program at Harvard Medical School, graduating in 1944 and then spending 1 year of internship at the Boston Children's Hospital. He was then in the U.S. Navy between 1945 and 1946. After decommissioning from the Navy, he spent 1 year as junior resident in surgery at Vanderbilt University. Beverly Douglas, a plastic surgeon, invited Harold Gillies to Vanderbilt, and Ralph was able to meet him and wrangle permission to become a trainee at Gillies' unit in Basingstoke, where he remained from 1948 to 1949. During his time in England, Millard enriched his training with Gillies by visiting all of the other important plastic surgeons in the United Kingdom, such as T. Pomfret Kilner at Oxford (where he learned cleft palate repair), Archibald McIndoe, Rainsford Mowlem, John Barron, and others. He was able to pay a visit to the ailing Victor Veau in Paris, who died several weeks after Millard's visit. He also became friends with other trainees who were with Gillies at the time, such as Jack Mustardé, Hugo Obwegeser, Jack Penn, and Ivo Pitanguy. After his 2 years of unaccredited training in Europe, Millard was able to find a position on the Plastic Surgery Service at Barnes Hospital, headed by James Barrett Brown, with Louis T. Byars, Frank McDowell, and Minot Fryer. The training was cut short at approximately 6 months when Dr. Brown, having had enough of Millard pointing out that Gillies would have done things differently, fired him. Millard found a job for the remainder of the year as cosmetic fellow with Claire Straith in Detroit, who had a busy rhinoplasty practice. After this, still needing a further year of residency to satisfy the requirements of the American Board of Plastic Surgery, Millard became the first plastic surgery resident in the new program headed by Barron Hardy at Baylor. Having finished this cobbled-together training in plastic surgery, Millard returned in 1952 to work with the now knighted Sir Harold Gillies on a book of Gillies' work. Gillies at this time was in the twilight of his career and would much rather have played golf (he had been a ranking amateur in the United Kingdom) or gone fly fishing for salmon than work on another book, but Millard held his feet to the fire, and the book was finally finished. Both Gillies and Millard saw nothing wrong with introducing a bit of wry humor into their medical writing, and the product of their collaboration was something new for medical publishing. New, and indeed disturbing for some, because a senior Boston plastic surgeon who was asked by a publisher to give his opinion said that the book should never be published, and that it would set plastic surgery back 25 years. Finally, Little, Brown and Company (who was to publish all of Millard's books and one of mine) took a chance, and The Principles and Art of Plastic Surgery was published in 1957. Gillies, in his 1920 book, Plastic Surgery of the Face, had listed a few basic principles, and these were expanded to 16 in The Principles and Art of Plastic Surgery. Not only were principles important in planning surgical procedures, but Millard extended them to all aspects of life, and if a resident did something louche or clumsy, we would tell him that “that's not very plastic.” After finishing his book with Gillies, Millard, because he had served only 1 year in World War II, found himself drafted for a second time. This time, he entered the Marine Corps and was sent to Korea. Because there was not much active fighting during the time he was there, he developed a busy reconstructive surgery service, caring for injured Korean soldiers from both sides of the conflict. A photograph taken at the time shows Ralph in camouflage pants and a white tee shirt, with a long line of patients with various types of tube pedicles waiting to see him. Millard stated that it was in Korea that the idea of the rotation advancement procedure (he often called it a principle) came to him when he was having a cat nap in front of a picture of a child with a cleft. In a moment of epiphany, he visualized the rotation and advancement flaps, and then marked them on the picture. Another story, perhaps intended to add to the legend, is that he found his first cleft patient for the procedure in a rice field and lassoed him with a rope trick he had learned during his year in Houston. Although the deadline for abstracts had passed, Millard, with help from Gillies, was able to get 5 minutes on the program of the meeting of the International Society of Plastic Surgeons in Stockholm, in 1955. Millard, ever the brash showman, stood in the back of the hall when it was time for his presentation, and began giving the talk as he slowly walked to the stage, where he used his full 5 minutes. After his second decommission from the military, Millard married Barbara Smith, whom he had met in San Diego before being shipped off to Korea. He briefly opened a practice in Beverly Hills, California, and in 1956 the Millard family moved to Miami. Here, the originator of the rotation advancement procedure found himself kept out of the cleft team, and to treat cases, he began making regular trips to the Bahamas and Jamaica. Between 1956 and 1970, Millard published a number of articles in Plastic and Reconstructive Surgery that were pioneering and remain classics. Besides his work in clefts (the rotation advancement for unilateral clefts, primary nasal correction, an approach to bilateral clefts that included columellar lengthening with forked flaps), there were articles on rhinoplasty, face lifting, primary jaw reconstruction, breast reconstruction, and other topics, all with superb results, beautifully illustrated, and written in his unique style. BECOMING CHIEF OF A SERVICE In 1967, Dean Warren, the chief of surgery at Jackson Memorial, asked Millard to take over the newly opened residency program on a “temporary basis,” because he was not a geographic full-timer. He remained in this “temporary” status for the next 25 years, and with the added responsibility of being a chief of service, the brash Millard of the past turned into a model of civility. Previously frozen out of a number of plastic surgery societies by people he had offended, Millard became accepted and became a director of the American Board of Plastic Surgery, and president of the Educational Foundation of the American Society of Plastic and Reconstructive Surgeons and the American Association of Plastic Surgeons. He later received honorary F.R.C.S. degrees from both London and Edinburgh. Millard over the years trained 176 residents and fellows, many of whom have gone on to become leaders in plastic surgery in the United States and abroad: presidents of the American Association of Plastic Surgeons and the American Society of Plastic and Reconstructive Surgeons (two), chairmen of the American Board of Plastic Surgery (two), the European Board of Plastic Surgery, the International Society of Craniofacial Surgeons (two), the American Society of Maxillofacial Surgeons, and the European Association of Plastic Surgeons. THE AUTHOR Millard was an insatiable writer. Besides the book with Gillies, he wrote the three-volume Cleft Craft, The Principlization of Plastic Surgery, and A Tetralogy of Rhinoplasty. His autobiography, Saving Faces, was published in 2003, 3 years after his retirement. Most of the writing for these books was done on a balcony overlooking Biscayne Bay. Millard would write in his neat and legible long hand on a yellow legal pad, and pass the pages on to a secretary for transcription the next day. Most of Millard's books have been digitized and they, and his autobiography, Saving Faces, can be obtained on request from [email protected]. RETIREMENT YEARS In 2000, Barbara Millard lost her toughly fought battle with lymphoma, and Ralph, still operating at 81, stopped to be with her during the last days. After she died, his family (sons Duke and Bond, and daughter Melaney) moved Millard to Houston and sold the family house at Bay Point, just north of Miami. Millard did not like Houston and returned to Miami the following year and bought a condominium on the ocean in Aventura, north of Bal Harbour. His youngest son, Bond, lived nearby, and helped take care of his dad, along with a part-time secretary, Louisa, and a housekeeper, Gloria. This was a difficult time for Ralph. He was not a gregarious person, and the great loves of his life, Barbara foremost, performing plastic surgery, and finally writing about it, were gone. Every few months, I would go up for a visit on a Sunday morning, taking visitors, residents, and fellows who wanted to meet the great man, and have him sign an inscription in one of his books. He paid several visits to us at our Miami Children's Hospital office to have a few skin cancer lesions removed. He died quietly in bed on a Sunday morning, several weeks after his 92nd birthday. HIS LEGACY Ralph Millard will be listed among the best—if not the best—American plastic surgeons of the twentieth century. His work in cleft lip and palate alone, which established him as the ultimate authority in this area, would be sufficient. He was a master of aesthetic surgery, with a long waiting list of face-lift patients ready to follow his demand that they have their surgery in the less-than-fancy accommodations of Jackson Memorial Hospital, which also provided most of the indigent care for South Florida. He was the Man in Miami for rhinoplasty, and had particular skill in difficult secondary cases. (Once he was on a panel at an American College meeting with Jack Anderson, one of the founders of the Facial Plastic Surgery Group. Someone asked them both about secondary cases. Anderson said that he was very careful, had very few revisions on his own patients, and did not do cases done by others. Millard paused, then said, “Yes, that's the difference between us: the buck stops here.”) Millard published some of the first cases of breast reconstruction (in the face of considerable criticism from the general surgery community), using tube pedicles to obtain results that would hold their own against contemporary methods, although the process was long and involved numerous delays of the pedicle as it was transferred. He was one of the first to perform primary reconstruction of the mandible after cancer resection (forehead flap for lining, rib graft for bone, and thoracoacromial flap for cover). He was a master of the forehead flap for nasal reconstruction, which he had learned from Gillies. Both Gary Burget (a resident) and Fred Menick (a fellow), our best makers of noses, got their start from Millard. Ralph Millard was the plastic surgeon's plastic surgeon, and was the one you would take your wife or child to if they needed either aesthetic or reconstructive surgery. Indeed, one of the leaders in the Facial Plastic Surgery Group brought his wife to Millard for a face lift. I will remember him as a big man, with big hands, seated on his stool (I gave him as a graduation present a pillow embroidered with a knight with a lance going off to battle, because every case was indeed a battle to obtain perfection), leaning over a small patient, with his Gillies needle holder in hand. We never really became close, as I did with Paul Tessier. Millard was a much less communicative person. After being in practice with him for 25 years, I finally asked him for a signed picture to hang on my wall. His inscription on the picture was “Tony, Plastic Surgery is not as easy as it seems!” That remains cryptic to me, but I think the greatest part of Ralph Millard's legacy is that he did break plastic surgery into a number of basic principles. Faced with a difficult reconstructive case, they are still useful: “put normal into normal position and keep it there”; “replace missing tissues with like”; and particularly, principle number 8, of the 32 listed in Principlization of Plastic Surgery, “know the ideal beautiful normal.” Constantly studying it, he, better than any of his contemporaries, was able to restore it.