Meet Harold Gillies, the WWI surgeon who rebuilt the faces of injured soldiers

In August 1917, a World War I British soldier named John Glubb was hit in the face by a shell. He recalled blood pouring out in "torrents" and feeling something akin to a chicken bone moving around his left cheek. It turned out to be half of his jaw, broken off by the impact. Glubb wasn't the only unfortunate WWI soldier to suffer a disfiguring facial injury. Shells filled with shrapnel were designed to inflict as much damage as possible, and the need to peer over the parapets of trenches to assess the battlefield or fire a shot meant a greater risk of getting hit in the face by bits of flying metal. Unlike losing a limb, these soldiers faced great social and professional stigmas when they returned home from the front because of their disfigurement. They were usually reduced to taking night shifts and relegated to special blue benches when out in public—a warning to others to avert their eyes. Fortunately for these men, a New Zealand-born surgeon named Harold Gillies devoted his life to developing innovative techniques for reconstructing faces after witnessing the carnage firsthand during his service at the front. Once home, he set up a special ward for soldiers with facial wounds at the Cambridge Military Hospital in Aldershot, eventually convincing his superiors that a dedicated hospital was warranted. He's often referred to as the "father of plastic surgery" because of his pioneering work at The Queen's Hospital (later renamed Queen Mary's Hospital) at Frognal House in Sidcup. Gillies is a key figure in a new book by author and medical historian Lindsey Fitzharris, entitled The Facemaker: A Visionary Surgeon's Battle to Mend the Disfigured Soldiers of World War I. A noted science communicator with a large Twitter following and a fondness for the medically macabre, Fitzharris published a biography of surgical pioneer Joseph Lister, The Butchering Art, in 2017—a great, if occasionally grisly, read. Her work soon caught the attention of the Smithsonian Channel, who tapped Fitzharris to host their 2020 documentary series revisiting infamous historical cold cases, The Curious Life and Death Of....  Fitzharris usually has several book ideas simmering on the back burner at any given time. For instance, she has a children's book coming out next year illustrated by her husband, cartoonist/caricaturist Adrian Teal, and is already working on a third book about a 19th-century surgeon named Joseph Bell, who inspired Sir Arthur Conan Doyle's Sherlock Holmes. The Facemaker was not her first choice for a follow-up to The Butchering Art, since she wasn't that knowledgeable about World War I. But her publisher loved the story of Gillies, so Fitzharris gave herself a crash course in the history of that period. "The Butchering Art is hyper-focused on one man, Joseph Lister, who applied germ theory to medical practice," Fitzharris told Ars. "This is a book not about one man, but many men. It's about Harold Gillies, the pioneering surgeon who rebuilt soldier's faces during the First World War, but it's also about these disfigured men. I hope that their voices really shine through in the narrative." Ars spoke with Fitzharris to learn more. (Warning: Some graphic facial reconstruction photos and descriptions follow.)

Ars Technica: This is such a massive topic. How did you narrow the focus so that the scope was manageable? Lindsey Fitzharris: It's true, it was a much more complicated story. I think that's why it took me five years to write, just coming to grips with the scale of World War I, with military medicine at that time, with all of these complicated advances. One of the challenges with World War I is there is so much material: so many diaries and letters by the soldiers writing about their experiences. Someone asked me what the difference is between academic history and the commercial history that I write. A lot of what I do now is discard information. I'm absorbing a lot in my research, but I'm pushing that away because I don't want to overwhelm the reader. I want to find the pulse of the story. I knew I wanted to drop the reader into the trenches right from the beginning. There's a man named Percy Clair who wrote this beautiful diary that allowed me to tell the story of what it was like to be injured, hit in the face, and lay on the battlefield for quite a long time before you were recovered. I wanted the readers to understand how difficult it was in the first instance just to get off the battlefield, and then to get to Gillies, because Clair was initially sent to the wrong hospital. There were also complications around accessing patient files in the UK, and what you can and can't say with regard to a patient's name. When I'm using a patient's name in The Facemaker, it's because that knowledge is public, or Gillies himself had published it at some point. If Gillies published about a certain patient, if I went into the case files and found further information that he hadn't included, I couldn't use that information in relation with that person's name. The Butchering Art didn't have that complication because it was set in the 19th century. Everything was old enough that we didn't have to worry about all of that. But a lot of the material for The Facemaker is in copyright. I had to contact Percy Clair's family members to get permission to quote from his diary to the extent that I did.

Ars Technica: Did you take any extra care when writing about what can be a rather sensitive topic, given that we're talking about serious facial injuries in veterans?  Lindsey Fitzharris: I had a disability activist read the manuscript, a wonderful author named Ariel Henley, who wrote a book called A Face For Picasso. She has a condition called Crouzon syndrome [a rare craniofacial disorder where the bones in the head fuse prematurely]. I wanted to get her thoughts on the language. For instance, I do call them disfigured soldiers in the book. That's not necessarily a term that people in the disability community would use today, and I'm open to that conversation. However, Ariel and I decided that this was an appropriate term because this is how these men were viewed in 1917 when they were injured. They faced real biases and prejudices because of their disfigurement. Ars Technica: Even today, facial disfigurement is something that seems to be more intensely personal than other kinds of disfigurement. Lindsey Fitzharris: Someone asked me if I thought that we'd come very far since 1917. I'm not a spokesperson for that community. But I would reckon that there are people today who have facial disfigurements who would recognize the biases and prejudice that, for instance, Percy Clair would've faced when he was injured in 1917. You only have to look to Hollywood and how they use disfigurement to signify evil. It's a lazy trope. You have Joker, you have Darth Vader, you have Voldemort, you have Blofeld. The list goes on and on. Harvey Dent in Batman Begins doesn't become evil until he's disfigured. Then he becomes Two-Face. These men faced enormous challenges when they left Gillies' hospital. If they left the hospital grounds to take a walk, they were forced to sit on blue benches so that the public knew not to look at them. Even in Gillies' hospital, mirrors were banned. This was done under the guise that it was for the patients' protection; you wouldn't want them to get frustrated with the reconstructive process. But it also instilled in them a belief that they had faces that weren't worth looking at. So they themselves had to overcome these biases, going from a typical face to—in some cases—severe disfigurement. It could be a really lonely journey. Arguably Gillies himself is the product of the facial biases that we have in society. You have to restore function, a person has to be able to swallow and to speak and to eat to some extent. But he went far beyond this, looking at the aesthetics of the face so that it would be deemed socially acceptable by the standards of its day. Facial injuries during this time warranted a full pension. You could have a facial injury and still be able to work. But it was deemed the worst kind of injury that you could get at this time, and so you would get the full pension.

Ars Technica: Let's talk about the decision to include certain graphic images of Gillies' patients in your book. There's an inevitable element of voyeurism to this. But you do need to convey the extent of their injuries and what Gillies accomplished surgically.  Lindsey Fitzharris: This is where Ariel's input was very useful. I felt strongly that I didn't want to put these men on the metaphorical blue bench in 2022. I think it's important that we look at them, that we understand what they went through and the extent of their injuries. It's difficult to visualize what Gillies was capable of doing so I felt was important to illustrate the actual work that was being done at that time. My husband is a caricaturist. A lot of times I had him read the patient files and describe what Gillies was doing with this flap, for instance, because my husband works in 3D characters. He was able to guide me through that complicated process. There were enormous numbers of photographs in the patient case files. A single patient might have upwards of 20-25 photos through their reconstructive process. So for the patients where I include their photos, I usually do so before they start their surgery, the middle process, and then the very end. But there was an exception. I decided not to include the photos of anybody who died in Gillies' care because they weren't able to complete their reconstructive process. There was a man named Ralph Henry Lumley who was terribly burned. He was a pilot who crashed his flight on graduation day. He never even made it into battle. It's a very sad story, and his case actually teaches Gillies an important lesson about plastic surgery. But he does die in Gillies' care. And in that case, I included a pre-injury photo of him in his uniform, and then a surgical diagram of what Gillies had planned to do if he could have finished the reconstructive process. Ars Technica:  I was fascinated by one method in particular: the tubed pedicle, designed to keep the blood flowing through the skin during the skin grafts.  Lindsey Fitzharris: That was one of his inventions. There's an argument, I think, to be made whether this was revolutionary or evolutionary. With The Butchering Art about Joseph Lister, he's breaking a paradigm. He's trying to convince people germs exist. There's a lot of pushback. Gillies' work is really born out of necessity. I would argue that Harold Gillies was more forward-thinking because he took a much more collaborative approach. A lot of surgeons were working solo on the reconstructive process. Gillies brought in artists and dentists, all kinds of people. And I think that helped usher in a new era for plastic surgery.

His tubed pedicle was a revolutionary technique. He later learned after the war that there were two other surgeons who had invented this technique simultaneously. They would take these skin flaps, which were attached to a blood supply, so they called it a pedicle. It was attached on one side and you'd move the soft tissue to the area that needed to be reconstructed. Before the tubed pedicle, the flap would remain open on the underside, so it was susceptible to bacterial infections. Gillies rolled it so that the soft tissue on the underside was encased in skin to protect it. Picture these long trunks of like skin and tissue that he would move all around the body. A lot of these patients had these huge tubed pedicles hanging off of their faces and various parts of their body. Gillies was able to do really miraculous work using those. Today the tubed pedicle isn't really used because there's been a lot of advances in micro- and vascular surgery. But at the time, it was really innovative. Ars Technica: Gillies ended up going into private practice for cosmetic surgery after the war, at the dawn of plastic surgery, which is a multi-billion dollar industry today. There were people who criticized him for that.  Lindsey Fitzharris:  I think he was self-critical at the beginning too. After the war, Gillies continued to operate on the soldiers because it could take over a decade to finish somebody's reconstructive work. But he had to move into the cosmetic realm to make money at the end of the day. He said that reconstructive surgery was about returning something to normal, whereas cosmetic surgery was about surpassing the normal. He was an innovative surgeon, and he was excited about those new challenges. He understood the psychological impact of even a slight flaw that other people might not notice; it could still have a huge impact on someone's personality or mood. So he felt that he was truly helping all of these patients.

The things that people were doing in the early 20th century could be really harmful. For instance, they were injecting paraffin wax into their face as a rudimentary filler. This would migrate and cause lumps under the skin. After the war, Gillies was approached to fix some of the harmful work that was being done in salons and other places outside of the medical realm. They were using X-rays to remove hair from women for a while, and a lot of those women got cancer. There's a story in the book's epilogue about a woman who had a horrible tumor growing on her face because she had undergone so many of these treatments. A surgeon removed the tumor, but in the process disfigured her. So she ended up in Gillies' care. Even today, people think of plastic surgery as purely cosmetic. But that's not true. There are still a lot of reconstructive surgeons. It's all very important to the discipline. Ars Technica:  Gillies never really stopped pushing medical and social boundaries. He also performed one of the earliest gender-affirming surgeries. That's something that is still quite controversial today. Lindsey Fitzharris: This is an amazing part of the story. Gillies was approached by a trans man named Michael Dillon to perform the first successful phalloplasty in 1949. Gillies went to great lengths to protect Dillon's identity while he was going through that process. Gillies himself was well placed to do this operation because he had been working on genital reconstruction on soldiers in World War II who had been injured. So again, there was the element of the challenge. He truly felt that Michael Dillon was going to benefit from the surgery. And he performed the surgery successfully.

Later, the British press outed Dillon as a trans man. The media frenzy ended up driving Dillon out of the country. There were a lot of people in 1949 who wouldn't have viewed Dillon as a man, but Harold Gillies wasn't one of them. He stood by Dillon through that whole process. That story shows his innovativeness, his progressiveness. He truly believed that people should be allowed to identify themselves, in terms of their appearance, however they wanted. Ars Technica: There are so many fascinating characters in your book. I personally had never heard of the French dentist and plastic surgeon, Charles Auguste Valadier. Lindsey Fitzharris: I love him. Valadier was a French-American dentist who owned this Rolls Royce that he retrofitted with a dental chair and drove to the front under a hail of bullets to help World War I soldiers—for free. He was one of the first to show Gillies that there was this huge need for facial reconstruction near the front. He's a legend. He was a real badass of surgery. His Rolls Royce went up for auction in 2013. Dentists weren't sent to the front at first, because teeth were not deemed that important during World War I. Teeth were very important in the 19th century. It was said that an army that can bite can fight, referring to the fact that you would have to bite the cartridge off to load the ammunition. That changed in World War I. But men were getting hit in the face and in the jaw area, so teeth ended up being very important in the end. People like Valadier were hugely instrumental in facial reconstruction at that time.

Ars Technica: What was the most interesting thing you learned over the course of writing the book? Lindsey Fitzharris: It wasn't just about learning weird factoids. This was about getting to know these men. One of my favorite stories was Private Walter Ashworth, who was injured on the first day of the Battle of the Somme. He ended up laying on the battlefield for three days without a jaw, unable to scream. He ended up in Gillies' care. His fiancee broke off the engagement, and her friend ended up writing Ashworth letters and visitng him in the hospital. They fell in love and got married. When he was discharged, he went back to work as a tailor's assistant. His boss made him work at the back of the shop because he didn't want Ashworth to frighten the customers. Ashworth was very hurt by this, and moved to Australia to build a new life. Many years later, Gillies bumped into him. At this point Gillies had really grown as a reconstructive surgeon and he asked Ashworth if he could have another go at his face. Ashworth declined, possibly because he had made peace with the face that Gillies had given him so long ago. It's a lovely story. A lot of these men ended up having very fulfilling lives, and they really appreciated what Gillies was able to do for them.