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Wendell Hughes and Plastic Surgery
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Here is a paper which describes the significant contributions of Wendell Hughes to the field of Plastic Surgery and Oculoplastic Surgery.

Here is a paper which describes the significant contributions of Wendell Hughes to the field of Plastic Surgery and Oculoplastic Surgery.

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Wendell Hughes and Plastic Surgery Document Transcript

  • 1. SPECIAL TOPICWendell L. Hughes’ Life and Contributions toPlastic Surgery W. Thomas McClellan, M.D. Summary: Wendell L. Hughes was a pioneer in ophthalmic plastic surgery and Ashley E. Rawson, M.D. best known for the “Hughes flap,” a tarsoconjunctival flap used for lower eyelid Morgantown, W.Va.; and reconstruction. In 1937, Wendell L. Hughes sought to achieve the criterion Lexington, Ky. standard of replacing “like with like” in his development of the tarsoconjunctival flap for lower lid reconstruction. This work was published in his ground-break- ing thesis, Reconstructive Surgery of the Eyelids, the most comprehensive book on ophthalmic plastic surgery of its time. Although this flap has undergone many modifications, it has stood the test of time and is still used today. In addition, Dr. Hughes was heavily involved in surgical education, a founding member of the American Board of Plastic Surgery, and a leader in the development of sutures and microneedles. More importantly, he was a gracious humanitarian and inspiring mentor loved by peers and patients alike. Other authors have reviewed the intricacies of the Hughes flap; however, little attention has been given to the contributions of its creator. (Plast. Reconstr. Surg. 128: 765e, 2011.) There is much to be done, but each step is a nibble at accompanying his father, the town physician, on the base of the mount of knowledge. The path up- house calls. In his acceptance speech for the Distin- ward is lined with many unknown obstacles, but we guished Service Award of the Nassau Surgical Society, cannot afford to rest on our laurels.1 Dr. Hughes fondly recalls childhood memories of —Wendell L. Hughes rounding with “a real country doctor, with his horseT his quote from Hughes exemplifies his life- and buggy over the single track dirt roads in the sum- long commitment to medicine and its prog- mer . . . to collect a ham, a gallon of maple syrup, a ress. Wendell L. Hughes (Fig. 1) was an early chicken, duck or a dozen eggs as a fee for a house call.”2pioneer of ophthalmic plastic surgery and laid the EDUCATIONfoundation for the progress of today. Would he have His formal education began in a one-roomthought a functional hand transplant was possible, country schoolhouse. He graduated high schoolor that a total face transplant could restore hope to and college from the London Collegiatea trauma victim? The work of Dr. Hughes and others Institute.3 He earned his Doctor of Medicine de-paved the way for the great advances of contempo- gree at the age of 22 years from the University ofrary plastic and reconstructive surgery. As a tribute, Western Ontario. Before starting residency, he fol-we investigate Dr. Hughes’ personal story and his lowed in his father’s footsteps, serving as a “coun-contributions to plastic surgery, ophthalmology, and try doctor, minus the horse and buggy, for 8the entire medical community. months in 1922.”2 He was then selected from over 120 applicants for one of 12 internship positions THE EARLY YEARS at Bellevue Hospital in New York.3 Here, he trained in general and ophthalmic surgery under Wendell L. Hughes (Fig. 2) was born on Febru- Dr. Charles May and Dr. John Wheeler.ary 26, 1900, in Thorndale, Ontario, Canada, a smalltown of 120 people. His childhood was enriched by LIFE AT HOME Dr. Hughes was strict and conservative, but a From the Department of Surgery, Section of Plastic Surgery, wonderful father. He taught many lessons to his West Virginia University School of Medicine, and the De- partment of Surgery, Section of Plastic Surgery, University of Kentucky College of Medicine. Received for publication January 4, 2011; accepted March Disclosure: Neither of the authors has any finan- 10, 2011. cial interests to report or has received any funds for Copyright ©2011 by the American Society of Plastic Surgeons the preparation of this article. DOI: 10.1097/PRS.0b013e318230c9f4 www.PRSJournal.com 765e
  • 2. Plastic and Reconstructive Surgery • December 2011 his daughters enjoyed this aspect of having a phy- sician for a father, they were not pleased when he practiced his operating techniques on the family rabbits and chickens. In response to the protests, Dr. Hughes would simply reply, “Would you rather me practice on a person?”3 Despite his dedication to medicine and his patients, Dr. Hughes loved to escape with his fam- ily to an island in Rideau Lake in Ontario, Canada, every summer. His industrious spirit was not lim- ited to medicine, as he spent numerous hours performing physical labor to spruce up the island.3 Hughes and his first wife, affectionately known as “Willie,” discovered this island during their hon- eymoon in 1929. Sadly, Willie died in 1953 of colon cancer. INTERESTS OUTSIDE OF THE HOSPITAL In addition to his interest in ophthalmologyFig. 1. Wendell L. Hughes in 1967, 1 year before his retire- and plastic surgery, Hughes also had a passion forment. (Photograph courtesy of the American Academy of tennis (Fig. 3) and boating (Fig. 4). He was aOphthalmology.) member of the Lighthouse Point Yacht and Rac- quet Club and could be seen every Thursday wear- ing his “inevitable port and starboard socks.” When questioned about this peculiar fashion statement consisting of one red and one green sock, he attributed the habit to his time in the boating world, when he wore them to help him “remember port from starboard.”4 Hughes showed his enthusiasm for tennis by donating medallions to the winners of the annual American Ophthalmology Society women’s tennis doubles tournament. These medallions were later replaced by the permanent Wendell Hughes Bowl.5 He began serious boating in 1955 and traveled up and down the East Coast to Canada a dozen times, an activity that both he and his second wife, Hassie, enjoyed. He pursued his interest to a higher level, publishing several articles in maga- zines such as Yachting, Boating, and The Mariner in addition to lecturing in boating courses offeredFig. 2. Wendell L. Hughes (below, right), with sister, Helen, and through the Lighthouse Point Yacht Club.3brother, Vernon, in 1905. (Photograph courtesy of his daughter,Margaret Smith.) THE ROAD TO OCULOPLASTIC SURGERY Historically, ophthalmic plastic surgical pro-children. He did not believe in self-promotion; cedures were performed by plastic surgeons untilinstead, he believed that one should be known for it became evident that greater anatomical andhis deeds and accomplishments and that others functional knowledge of the eye promoted betterwould recognize this. He never swore, and be- results with fewer complications. The gradual for-lieved that if you did not have anything nice to say mation of oculoplastic surgery as a subspecialtythen you should say nothing at all.3 was stimulated by Hughes’ most influential Like his father, he often brought his daughters teacher, Dr. John Wheeler. Hughes trained underto the hospital for rounds before school. Although Wheeler at Bellevue Hospital from 1924 to 1935 and766e
  • 3. Volume 128, Number 6 • Contributions of Wendell L. Hughes Fig. 3. Hughes (right) during a tennis match with Peter Ballen in Hong Kong in 1963. (Photograph courtesy of his daughter, Margaret Smith.) Fig. 4. Hughes in the captain’s seat. (Photograph courtesy of his daughter, Margaret Smith.)later served on his staff at Bellevue and the New York American Academy of Ophthalmology and Oto-Eye and Ear Infirmary. The dedication of Hughes’ laryngology in the late 1920s. During the firstground-breaking thesis, Reconstructive Surgery of the course, he covered the entire subject in 1 hour.7Eyelids, the most comprehensive book on oculoplas- Dr. Wheeler not only was an expert in plastictic surgery of its time, reveals Wheeler’s tremendous surgery but was also a founding member of theinfluence: “Dedicated to the memory of Dr. John Board of Plastic Surgery. Shortly after its establish-Martin Wheeler whose skill in the art of ophthalmic ment, Dr. Hughes was nominated for membershipplastic surgery and indefatigable patience in teach- in the Board’s Founders Group. In February of 1940,ing it, stimulated the author’s special interest in the Hughes received a Certificate of Qualification as asubject matter of the present thesis.”6 Specialist in Plastic Surgery. Thus, Hughes stood at Dr. Wheeler trained in New York and then the forefront with several other founding membersserved in the military during World War I, obtain- of the Board of Plastic Surgery, including the likes ofing significant experience on the trauma service. George Pierce, Robert Ivy, and John Davis.8He developed a strong interest in oculoplastic sur-gery, and his extensive case reports were published COMMITMENT TO EDUCATIONin the Columbia University Press and were later After Wheeler unexpectedly died while work-combined as the Collected Papers of Dr. John Martin ing on a stone fence at his family farm in Vermont,Wheeler.7 Wheeler also led the first instructional Hughes began teaching the ophthalmic plasticcourse devoted to oculoplastic surgery at the surgery course of the American Academy of Oph- 767e
  • 4. Plastic and Reconstructive Surgery • December 2011thalmology and Otolaryngology. Hughes was an Hughes served as President of the Americaneducational pioneer and was one of the first to Academy of Ophthalmology and Otolaryngologyteach key principles and surgical technique using in 1967 and President of the American Society ofmotion pictures. He believed that if you knew the Ophthalmic Plastic and Reconstructive Surgery inbasic principles well, you could apply them to even 1969. He also chaired the Academy’s Plastic Sur-the most challenging cases. He presented his lec- gery Committee from 1952 to 1968 and was pri-tures in a detailed clinical way so that all in atten- marily responsible for writing and editing the firstdance could perform the procedure after finish- edition of the Academy’s manual, Ophthalmic Plas-ing the lecture.9 Because of increased demand, the tic Surgery, in 1961.5 His educational legacy con-instructional period was subsequently increased to tinues with the annual Wendell L. Hughes Lecture3 hours of lecture and to two full panels, with Award established by the Academy in 1970. HisHughes leading one and his fellows Byron Smith former fellows Byron Smith and Alston Callahanand Alston Callahan leading one.7 Dr. Hughes also were the first two recipients. The Hughes Medalpresented at many early American Society of Plas- (Fig. 5), designed by Byron Smith and commis-tic and Reconstructive Surgery meetings, includ- sioned by Tiffany & Co., was presented to theing a lecture on orbit reconstruction at the 17th annual Hughes Lecture Award recipient, but wasAnnual Meeting at the Greenbrier Resort in Lewis- discontinued after the first 2 years because of itsburg, West Virginia.3 high cost.11 Dr. Hughes inspired and motivated his stu-dents, training over 75 fellows. Several achieved EVOLUTION OF SUTURES ANDtheir own fame, including renowned oculoplastic NEEDLESsurgeon Byron Smith, who left Yale to train under Dr. Hughes was instrumental in the develop-Hughes. Together, they opened the first exclusive ment of improved microneedles and sutures. Hisoculoplastic surgery clinic in New York in 1941.10 first experience with sutures came at the age of 3,They later moved the clinic to Cornell University when he suffered facial lacerations and fracturesaccording to Dr. John Converse’s request.11 after being kicked by a horse. He commented that Hughes not only taught his fellows the tech- “the heavy needles and coarse sutures left perma-nical aspect of oculoplastic surgery but also em- nent scarring and sutures marks that would bephasized their ethical responsibilities. His guiding quite unacceptable today.”12ethical principle was that operating on a patient is Dr. Hughes was an intense worker who alwaysa sacred honor and that one must practice under sought to improve current techniques and instru-the highest possible standards.9 ments. In a time when the atraumatic aspect of Fig. 5. The Hughes Medal. (Photograph courtesy of the New York University Department of Ophthalmology.)768e
  • 5. Volume 128, Number 6 • Contributions of Wendell L. Hughessurgery was not emphasized and virtually all pro- simultaneously create the transverse fold of the up-cedures were performed through large, cumber- per lid.13 Overall, this technique led to significantsome incisions, Hughes was meticulous and gen- improvement in both form and function.tle, combining the precision and delicacy of eye Hughes also made great contributions to thesurgery with oculoplastic surgery.9 However, atrau- field of comprehensive ophthalmology, includingmatic technique was difficult to practice without the combined operation for cataract and glau-the proper tools. Thus, in 1950, Hughes and five coma in 1928 at the New York Eye and Ear Infir-ophthalmologists met with Howard Zoller, an in- mary. He was initially severely criticized at thefluential suture company representative, to discuss American Ophthalmological Society meeting,problems with sutures and needles. This meeting where he reported 29 cases of this combined op-sparked the development of a surgeon-company eration, in which normal tension and vision wereliaison that had its first meeting in 1953, in which restored in all but one case, and further vision lossZoller’s company gathered 22 ophthalmologists caused by uncontrolled glaucoma was preventedfor an in-depth discussion of needles and sutures in 28 of 29 cases.14 Despite this early criticism,at the annual meeting of the American Academy Hughes successfully reported over 300 cases of thisof Ophthalmology and Otolaryngology. So many combined operation, and the combined proce-problems were discussed that an annual meeting dure is now the standard of care.4was established, with Hughes elected chair and Not only did Hughes pioneer new techniques,serving in that role through the 1965 meeting. he also invented new tools to assist in the educa-Other surgical subspecialties quickly followed suit. tion of future ophthalmologists and oculoplasticThe Plastic Surgery Panel was established in 1957 surgeons alike. In 1932, Hughes was granted aand chaired by Dr. Bradford Cannon.12 patent for an ophthalmotrope, a device that would Hughes worked tirelessly with the panel and represent the globe and “accurately demonstratesuture manufacturers to discuss problems and, muscle actions of the eyes, which will demonstratemore importantly, use solutions that have led to certain surgical operations relating to eyes and thethe creation of many surgical products allowing results thereby accomplished, which can be ma-for the intricate techniques necessary for the su- nipulated to show all actions of the eyes . . . andperior results that have become the standard in further to show the related muscles cooperating toplastic surgery. Reverse cutting needles were the give like movements of the eyeballs.”15first products promoted by the panel. These nee-dles provided extra sharpness needed in ophthal- The Origins and Evolution of the Hughes Flapmic surgery and provided 40 percent more Arguably, Hughes’ most famous contributionstrength than their cutting-eyed counterparts.12 to oculoplastic surgery was the tarsoconjunctivalThe reverse cutting needle is now commonly used flap, proposed in 1937 and now known as thein plastic surgery— especially cosmetic proce- “Hughes flap.” Before exploring the origin anddures, where minimal trauma, early regeneration evolution of this flap, it is important to understandof tissue, and minimal scar formation are of pri- the developments that preceded it and influencedmary concern. its creator. Jacques Reverdin conclusively demonstrated NEW TECHNIQUES AND INVENTIONS free skin grafting in 1869. He showed that a com- In addition to improving needles and suture pletely detached piece of human epidermis wouldmaterials, Hughes pioneered many new surgical remain viable with creation of a proper bed, pro-techniques. In 1955, he described a method for tection, and appropriate contact until tissue unioncorrecting congenital palpebral phimosis, a spec- had occurred. He demonstrated this by transfer-trum of deformities characterized by a wide inter- ring small pinch grafts of skin including the stra-canthal distance with various types of epicanthal tum mucosum that enlarged, providing true epi-skin folds located at the medial canthus. He pro- thelialization of the affected area and causingposed a Y-V operation that involved several steps: rapid healing of the granulation tissue.6 Although(1) elongation of the lateral canthus; (2) shifting free skin grafts were controversial initially, his ar-the medial canthus nasally and posteriorly, with ticle sparked important developments. Leon Lerecreation of medial canthal depression through re- Fort initially condemned this idea but later devel-moval of soft tissue; (3) relocation of the lower lac- oped the eponymous full-thickness graft tech-rimal punctum; and (4) resection of the levator pal- nique eventually used by Hughes.pebrae superioris, which would serve to increase the Another point that had been previously ne-vertical diameter of the interpalpebral fissure and glected was the use of one lid structure to rebuild 769e
  • 6. Plastic and Reconstructive Surgery • December 2011another (i.e., replacing “like with like”). Grad- Wheeler, who stated that “this is one of the mostenigo first proposed the idea in 1870, stating that splendid results of plastic surgery about the eye I“nothing will reconstruct satisfactory lids as well as have ever seen .... In operations similar to this Inormal lid tissues themselves.”6 Therefore, this ledto the notion that skin should replace skin, tarsusshould replace tarsus, and so forth. How did Hughes get the idea to replace lowerlid with upper lid? According to Hughes, it was notuntil the works of Dantrelle and Tartrois in 1918and of his mentor John Wheeler in 1921 that thefree grafting of large areas of upper lid to serve asthe donor site for lower lid reconstruction wasproperly emphasized. The upper lid skin providesa perfect match for the lower lid in every aspect—color, texture, thickness, and pliability.6 In his the-sis, Hughes displays the influence of Le Fort andWheeler, by combining their ideas in two casereports to recreate a lower lid using a full-thicknessgraft from the upper lid. In 1932, he further proposed a lower lid re-construction technique that recreated the con-junctiva. At that time, the current thought was thatlining a graft would cause its demise secondary toinadequate circulation.16 Hughes criticized cur-rent methods such as sliding and pedicle flaps fortheir lack of lining, because failure to reconstructthe conjunctiva led to inward curling of the skinedges. Hughes emphasized that “this rough edgewith its rigid epithelial edge and the innumerableminute hairs which are always present usuallycauses irritation of the eye.”16 Standing his ground just as in 1928 with hiscombined cataract operation, Hughes chargedforward and challenged popular belief. He dem-onstrated that if “sufficiently large raw area is lefton the graft, the lined area is not made too large,and the bed for the graft is properly prepared, theoperation can be successfully performed, as dem-onstrated in the procedure here reported.”16 Thestages of the procedure are as follows. First, theupper and lower lid margins are denuded andapproximated with a double-armed suture. Simul-taneously, a pocket is made in the upper lid toencompass a donor graft of mucous membranefrom the patient’s cheek that will become the con-junctiva of the newly reconstructed lower lid. Sec-ond, after 3 weeks, the skin and mucous mem-brane lining from the upper lid are removed andtransplanted to the lower lid. Third, after 6 weeks,the lid adhesion is severed to create the interpal-pebral fissure.16 Fig. 6. (Above) A long, shallow, 75 percent lower eyelid defect. Hughes presented this work before the Oph- (Center) Intraoperative view showing inset of the Hughes flap tothalmology Section during the New York Academy repair the posterior lamella. (Below) Postoperative view after aof Medicine meeting in 1933. Present at this meet- full-thickness skin graft to repair the anterior lamella. (Photo-ing was none other than Hughes’ mentor, John graphs courtesy of Mark Codner, M.D., and W. T. McClellan, M.D.)770e
  • 7. Volume 128, Number 6 • Contributions of Wendell L. Hughes tarsus and an outer flap composed of subcutaneous tissue, skin, and eyelashes.17 The dissection of the upper lid extended 3 mm beyond the tarsus, without disturbance of the at- tachment of the levator to its upper border.17 The lower epithelial border of the upper tarsus was united to the conjunctival margin in the lower fornix to reform the posterior lamella, and the previously undermined cheek skin was attached to the anterior surface of the tarsus to rebuild the anterior lamella. The second stage of this procedure involved transplanting the lashes. Finally, the third stage required a transverse incision between the two rows of lashes and through skin and the tarsus toFig. 7. The S.S HOPE. (Photograph courtesy of the Project HOPE open the interpalpebral fissure.17 Hughes laterWeb site.) became aware of similar procedures in the liter- ature by Kollner and Dupuy Detemps. Not want- ing to take credit away from those who deserved it,have never dared to throw a flap from the upper Hughes addressed this in his thesis but stated thatto the lower lid the way that Dr. Hughes did. He his procedure differed from both of these tech-showed his skill in plastic surgery in taking the skin niques in essential details.6from the upper lid so that vitalization was possible; To further improve his procedure, Hughesthen by uniting mucous membrane to mucous published a response dealing with technical de-membrane, he obtained vitalization without any tails of the tarsoconjunctival flap, addressing sev-loss of tissue. I think this is quite a feat.”16 eral of the most frequently encountered compli- In 1937, Hughes built on his success and cations of the procedure: permanent loss of somesought to achieve the criterion standard of replac- or all lashes, entropion of the lid margin, anding like with like by developing the tarsoconjunc- retraction of the upper lid. To resolve the problemtival flap. Instead of recreating the conjunctiva of lash loss, he revised the transverse incision,using mucous membrane from the cheek, he used isolating the tarsoconjunctival layer. He proposedconjunctiva from the ipsilateral upper lid. This tar- making the incision farther back and obliquelysoconjunctival flap involved a three-stage procedure, incising the tarsus to avoid traumatizing the rootmuch like his aforementioned operation. The first bulbs of the lashes.18stage involved undermining the skin of the cheek to Hughes also addressed the problem of retrac-allow it to occupy the space of the former lower lid tion and entropion of the upper lid margin. Hewithout tension. Next, the upper lid was split into two stressed the importance of extension of the upperflaps: an inner flap composed of conjunctiva and lid tarsus dissection to the proper height and sev- Fig. 8. Dr. Hughes (center) in the operating room, educating those around him. (Photograph courtesy of his daughter, Margaret Smith.) 771e
  • 8. Plastic and Reconstructive Surgery • December 2011ering the levator and the Muller muscle attach- ¨ W. Thomas McClellan, M.D.ments from the tarsal surface.18 Morgantown Plastic Surgery Associates United Center, Suite 350 The Hughes flap has undergone several mod- 1085 Van Voorhis Roadifications, including revision of the tarsus dissec- Morgantown, W.Va. 26505tion to leave a portion in the donor site to decrease wtmcclellan@yahoo.compostoperative deformity, mobilization of the or-bicularis oculi to provide a vascular bed for thefull-thickness skin graft, and use of a free tarso- ACKNOWLEDGMENTSconjunctival flap to achieve a one-stage procedure The authors thank Margaret Smith, Nancy Taylor,for monocular patients.19 Despite these modifica- Jack Eckert, Dr. Richard Lisman, and Dr. Orkan Stasiortions, Hughes’ procedure has stood the test of for sharing personal details about Dr. Hughes. Withouttime. The Hughes flap (Fig. 6) remains a useful them, this article would not have been possible.technique that has improved patients’ lives for REFERENCESover 70 years by replacing like with like to produce 1. Hughes WL. The development of ophthalmic plastic surgery.excellent results in both form and function. Adv Ophthalmic Plast Reconstr Surg. 1986;5:15–23. 2. Hughes WL. Acceptance of the 1986 Distinguished Service THE FINAL YEARS Award of the Nassau Surgical Society. June 21, 1986. Although Dr. Hughes retired in 1968, his con- 3. Smith M. Personal communication, 2009.tributions to society and the medical community 4. Full text of the American Academy of Ophthalmology and Otolaryngology, oral history recollections of past and presentdid not stop there. Inspired by Dr. William B. leaders: Oral history transcript/1998-[ongoing]. Internet Ar-Walsh, who served as a medical officer during chive. 1996. Available at: http://www.archive.org/stream/World War I, the S.S. HOPE (Fig. 7) was designed opthamology00spenrich/opthamology00spenrich_djvu.txt.to be a floating hospital center to provide health Accessed October 31, 2009.care and education around the world. Once 5. Beard C, Wendell L. Hughes, MD. Trans Am Ophthalmol Soc. 1994;92:16–18.completed, a call was “put out for American 6. Hughes WL. Reconstructive Surgery of the Eyelids. St. Louis:doctors, nurses, and technologists to share their Mosby; 1943:42–103.skills and knowledge with the people of devel- 7. Hughes WL. Personal remembrances regarding plastic sur-oping nations - teaching while healing.”20 Dr. gery in ophthalmology. (Unpublished book chapter).Hughes answered this call, and he and his wife 8. Eckert J. Personal communication, 2009. 9. Stasier O. Personal communication, 2009.Hassie served in Tunisia, providing medical and 10. Ittyerah TP. Ophthalmic plastic surgery. Indian J Ophthalmol.surgical services and teaching. 1988;36:109. Dr. Hughes died on February 10, 1994, at the 11. Lisman R. Personal communication, 2009.age of 93. Instead of flowers, donations were given 12. Hughes WL, Castroviejo R, Blaydes JE, et al. The evolutionto the Florida Lions Eye Bank, a nonprofit orga- of ophthalmic sutures. Ann Plast Surg. 1981;6:48–65. 13. Hughes WL. Surgical treatment of congenital palpebral phi-nization providing donor eye tissue to ophthal- mosis: The Y-V operation. AMA Arch Ophthalmol. 1955;54:mologists for corneal transplantation, in addition 586–590.to supporting a pathology laboratory for the study of 14. Hughes WL. Results of a combination operation for cataracteye disease and providing resources and tissue for with glaucoma. Trans Am Ophthalmol Soc. 1955;53:127–149;teaching and research.21 Even in death, Dr. Hughes discussion 150–154. 15. Hughes WL. Ophthalmotrope. U.S. patent 1,881,602. Octo-continued to contribute to the lives of patients and ber 11, 1932.the advancement of medical education. 16. Hughes WL. Removal of the lid with plastic repair. Arch Ophthalmol. 1933;10:198–201. CONCLUSIONS 17. Hughes WL. A new method for rebuilding a lower lid: Report Wendell L. Hughes (Fig. 8) was an inspiring of a case. Arch Ophthalmol. 1937;17:1008–1017. 18. Hughes WL. Total lower lid reconstruction: Technical de-mentor, a gifted educator, a gracious humanitar- tails. Trans Am Ophthalmol Soc. 1976;74:321–329.ian, and a pioneer in the field of plastic surgery. 19. Rohrich R, Zbar R. The evolution of the Hughes tarsocon-He was a surgeon loved by his patients and re- junctival flap for lower eyelid reconstruction. Plast Reconstrspected by his peers and whose contributions are Surg. 1999;104:518–522; discussion 524–526.profound. As the breadth of plastic surgery ex- 20. Project HOPE. History of Project HOPE, 2009. Available at: http://www.projecthope.org/ourmission/history.asp. Ac-pands, we as a profession need to strive for the cessed October 31, 2009.high ideals held by Dr. Hughes, both in the op- 21. Florida Lions Eye Bank. History of Florida Lions Eye Bank.erating room and at the bedside. Available at: http://www.fleb.org/. Accessed October 31, 2009.772e