Prevention by organization: The story of No. 4 Maxillofacial Surgical Unit in North Africa and Italy during the Second World War

Background: Written to commemorate the 60th anniversary of Victory in Europe, this article outlines the experience of No. 4 Maxillofacial Surgical Unit, stationed near Cassino, Italy, during the Allied assault in 1944. Methods: Private archive material including the original data and case photography are used to illustrate the problems of severe maxillofacial injury and burns management in the theater of war. Trained by Harold Gillies, Patrick Clarkson was commanding medical officer of this small innovative unit. With his trainee Rex Lawrie, he overcame huge surgical challenges using the tool kit of wartime plastic surgery. Results: Between 1942 and 1945, they managed 5000 casualties, including 3000 maxillofacial injuries and 1000 burns. To cope with such numbers, the Unit developed novel and aggressive strategies that opposed contemporary conservative practices. These included early primary closure of missile wounds to the face, which reduced union time for fractures and halved the number of late sequestrectomies. Early excision and skin grafting of large burns resulted in the successful management of burns of up to 72 percent body surface area, marking a shift toward the modern era of surgical burns excision. Cases presented include the first report of skin grafting to the calvarial diploe and a series of medullary bone grafts to restore frontal contour defects. Conclusions: The drive to return injured men to duty without evacuation put great evolutionary pressure on the development of plastic surgery, and much is strikingly recognizable in current practice 60 years later. Were these early surgical lessons forgotten?.