History of plastic, reconstructive and aesthetic surgery in Kenya. By Dr Robert Kyalo Mbaluka, University of Nairobi, Kenya

1. HISTORY OF PLASTIC,
RECONSTRUCTIVE AND
AESTHETIC SURGERY
DR. KYALO
PRAS III
10TH DECEMBER 2020

2. Definition
• The word “plastic” comes form “plasticus”, which is a
Latinization of the ancient Greek adjective “plastikos”
(“πλαστικός”, “fit for moulding”).

3. Historical definition
• 1597, the Bolognese Gaspare
Tagliacozzi (1545–1597), gave the
following definition of our
discipline:
to “restore what Nature has given
and chance has taken away. The
main purpose of this procedure is
not the restoration of the original
beauty of the face, but rather the
rehabilitation of the part in
question”.

4. The distant past and the wound as a problem
• The ancient origin of plastic surgery relates to the healing of
wounds.
• Transform a defect that heals slowly by 2° intention into one
healing quicker by 1° intention.
• Used, fibers or strips of tendon for sewing, or pinned
together using insect mandibles.
• Bronze pins.

5. In Ancient Egypt
• 3000 to 2500 BCE – Edwin Smith Papyrus
• Contains descriptions of broken noses and their repair.
• Fresh wounds – grease and honey, linen and swabs, strips of
cloth, a clamp and stitches

6. In Mesopotamia
• 2000 BCE to 600 BCE
• Congenital anomalies
• “If a man is sick with a blow on the cheek, pound together
turpentine, tamarisk, daisy, flour of Inninnu strain mix in milk
and beer in a small copper pan; spread on skin and he shall
recover.”
• Use of a dressing with oil for an open wound.

7. In India
• 600 BC – Sushruta, Indian physician
• Samhita (a Sanskrit text on surgery attributed to Sushruta) -
reconstructive procedures of face
• Entropion, trichiasis, and repair of the nose is reported.
• Indian Koomas - Repair of the nose
Local flaps,
Blunt (yantra) and sharp (sastra) instruments used

8. Indian forehead flap nasal reconstruction. (Gentleman’s Magazine. 1794;64:891–892.)

9. In Rome
• 30 AD Aulus Cornelius Celsus (25BCE - 50AD) – De
Medicina (On Medicine)
• Vessel ligature, lip closure (cleft lip or lip tumor) by
use of flaps
• Advancement flap
• Cardinal signs of acute inflammation, “redness and
swelling with heat and pain” (rubor et tumor, cum
calore et dolore)

10. In Rome
• (c. 129–201 AD) Claudius Galen
• Asklepieion,
• Physician, surgeon & philosopher in Roman Empire
• Wounds - sutures and cautery

11. Plastic surgery after the decline of the Roman Empire
• 325 – 403 AD Oribasius
• Synagogae Medicae - cheek, nose, ears, and eyebrow defects
• 625 – 690 AD Paulus of Aegina
• Medical encyclopedia (Epitome)
• Book 6 - ectropion, upper eyelid retraction and lip repair

12. The Middle Ages - Arabian surgery
• 936 – 1013 AD Abū-l- Qāsim or Albucasis
• Al Tasrif (On Surgery – 1500 AD) - > 200 illustrations of
surgical instruments e.g. cauteries
• Cauteries – use in wounds and cleft lips.

13. The Renaissance
• 1510 – 1590 Ambroise Paré, a barber-surgeon
• Wounds - dressings and ointment of egg yolk, oil of roses
& turpentine
• Cleft lip suture in medical literature.
• Adhesive and wound margin fastening

14. Service of the Eyes
• 1583 - Blepharoplasty
• Georg Bartisch (1535–1607) -
Ophthalmodouleia, or the Service of
the Eyes
• Blepharochalasis, a guillotine.

15. On the Surgery of Injuries by Grafting
• 1597 AD
• De Curtorum Chirurgia per Insitionem (On the Surgery of Injuries by
Grafting), published in Venice in 1597, by Gaspare Tagliacozzi
(1544–1599), Professor of Surgery at Bologna University.
• Nasal reconstruction procedure is shown step by step and skillfully
illustrated.

16. Nasal reconstruction with the arm flap.
(A) Preoperative view of the patient. The missing nose and flap are outlined.
(B) The flap sutured into position.
(C) Final result. (Tagliacozzi G., De Curtorum Chirurgia per Insitionem)

17. Rhinoplasty
• 15th C
• Branca family from Catania (Sicily); Gustavo – cheek
Antonio – arm flap
• In Calabria (Southern Italy)
• Vincenzo Vianeo – arm flap rhinoplasty
Pietro (about 1510–1571) and
Paolo (about 1505–1560) - Rhinoplasty clinic in
Tropea (Calabria).
• Captured in Leonardo Fioravanti (1517–1588) Tesoro della Vita
Humana (Treasure of Human Life) issued in Venice in 1570.

18. The decline of plastic surgery
• 17th and 18th C
• Fallopio (1523–1562), Heister (1683–1758), Camper (1722–
1789)
• Epithesis – wood, silver.

19. Rebirth of plastic surgery - “my God, there is a nose!”
• 1814 Joseph Constantine Carpue - Forehead flap rhinoplasty
Nasal reconstruction with the forehead flap. (A) Preoperative view. (B) The flap transposed into position.
(Carpue JC. Restoring a Lost Nose from the Integuments of the Forehead, in the Case of Two Officers of his
Majesty’s Army. London)

20. The 19th century - The golden age of plastic surgery
• Carl Ferdinand von Gräfe, compared the Italian and Indian
procedures in Rhinoplasty: or the Art of Reconstructing the
Nose
• Carpue’s and von Gräfe’s publications - European interest
• Johann F. Dieffenbach, Germany - rhinoplasty, facial
restorations, cleft lip & palate repairs.
• Jacques Mathieu Delpech, France –Rhinoplasty
• Pancoast, US, Balassa, Hungary and Sabattini in Italy
• With Anesthesia (1846), donor site 1°closure, forehead
rhinoplasty preferred due to simplicity, color match and
excellent results

21. Autologus Skin Graft
• 1804 Giuseppe Baronio - autologous skin graft in a ram in 1804
• 1869 Jacques Reverdin - first successful epidermic graft on a human
• Louis Ollier - split-thickness skin graft
• Carl Thiersch (STSG) & John R Wolfe - advances in the procedure.
• In the late 1800s - skin grafting, preferred solution for chronic wounds
and granulating wounds
• Humby 1936 – Modified Graft cutting razor
• Otto Lanz 1907 – Mesh graft
• Ioannis Yannas & Dr. John F. Burke 1970’s – Artificial skin ‘Integra’

22. Modified graft cutting razor” described by Humby in 1936
Integra Dermal Regeneration Template™ (Integra DRT)

23. The 20th century & Origin of modern plastic surgery
• WW1 soldiers, major maxillofacial mutilations,
• Development of a new discipline, reconstructive surgery.
• Hippolyte Morestin (1868–1919), dentist Charles Auguste Valadier
(1873–1931) Hôpital Valde-Grâce (Paris) - MDT approach.
• 1915, Harold Gillies - Queen’s Hospital, Sidcup. Face and jaw
injuries.
• Gilles MDT team - William Fry and and Henry Pickerill (dental
surgeons) and anesthesiologists.

24. Harold Gillies – Gillies forceps
• Gillies - tubed flap, skin flaps, bone,
cartilage, and skin grafts.

25. The interior of the plastics theatre, at the Queen’s hospital with Gillies seated on the right.

26. Walter Yeo, wounded in 1916. Managed using a ‘tubed pedicle flap’

27. Sequelae of facial burn from World War I. Repair using the tubed flap.
(A) Preoperative view of the patient. (B) Outlining of the tubed flap. (C) The flap in position. (D) Final result.
(B) (Reproduced from Gillies H. Plastic Surgery of the Face. London: Frowde, Hodder and Stoughton; 1920.)

28. Lieutenant William Spreckley after surgery. Gillies, implanted a shaped piece of cartilage to
give him a cartilage graft to create a nasal bridge.

29. Private Arthur Mears is captured during treatment (left) and afterwards (right) following
the repair of his jaw using his rib.

30. The training programs
• UK - Queen’s Hospital at Sidcup, Sir Harold Gillies, famous for
facial injuries
• Other training programs in the UK, by Sir Archibald McIndoe,
Rainsford Mowlem, and Pomfret Kilner.
• Paris, France - Fernand Lemaître (1880–1958) - Residency at
the International Clinic of Oto-Rhino-Laryngology and Facio-
Maxillary Surgery,
• Milan, Italy - The Pavilion for Facial Cripples, headed by G.
Sanvenero Rosselli
• US - by Vilray Blair at Washington University in St. Louis.

31. The scientific journals
• Revue de Chirurgie Plastique - Gillies, Maliniak, and Rethi,
• Lasted until the end of 1938 (8 years) due to WW II.
• 1946, Plastic and Reconstructive Surgery Journal – Warren B. Davis

32. Postwar plastic surgery
• 1960s - arterialized flaps, culminating with their microvascular
transfer.
• Musculocutaneous flaps - Italian Iginio Tansini (1855–1943)
• 1960s - Craniofacial techniques, developed by Paul Tessier
(1917– 2008)
• Systematization of breast reconstruction
• Fat grafting for numerous aesthetic and reconstructive
indications,
• Most recently, face transplantation, constitute further
achievements of our specialty.

33. Aesthetic surgery - The origin
• 1845, Johann F. Dieffenbach – Nasal hump rhinoplasty
• A few years later - Julius von Szymanowsk. Handbook of Operative
Surgery
• 1881, Edward Ely in NewYork - Correction of prominent ears and
modifications of nasal appearance
• 1887, John Orlando Roe - reduction of a bulbous or “pug nose,”
under LA.
• 1891, John Orlando Roe - hump removal using scissors
• 1892, Robert Weir, New York - alar base excision, “Weir operation”,
to lower an over projected nose
• ?1931 Jacques Joseph, Berlin – Codified Aesthetic rhinoplasty
steps

34. Aesthetic surgery - The origin
• Aesthetic surgery boom - in Europe & US between the two world
wars.
• Problem of quacks - crude rubber mixed with gutta-percha and
ground in a mill for fillers
• Plastic surgical societies - establish a barrier against quacks
• 1920’s Suzanne Noël ,Paris, successful solo practice, facial
rejuvenation, abdominoplasty or mammoplasty.
• 1926, she published La Chirurgie Esthétique. Son Rôle Sociale, one
of the first textbooks on this topic and the first written by a woman.
• 1929, Julien Bourguet - transconjunctival blepharoplasty
• 1901, Eugen Holländer - reported on a facelifting

35. Postwar aesthetic surgery
• Increase in number of plastic surgeons
• Improved techniques for noses, faces, necks, eyelids, ears, chins,
• breasts, and abdomens
• 1960’s New solutions – e.g. hypoplastic breast – silicone mammary
prosthesis in mid-1960s
• 1980’s – Liposuction
• Faceliftings, fillers, botulinum toxin, and fat injection favorably
improved the demand for facial rejuvenation.

36. THE HISTORY OF PLASTIC SURGERY IN KENYA.
• 60 years ago
• Tremendous growth

37. HISTORY OF PLASTIC SURGERY IN KENYA
• 1956, Ol Orien Farm, Mt Kilimanjaro slopes –
3 men, Sir Archibald “Archie” McIndoe,
Sir Michael Wood
Dr. Tom Rees, all reconstructive surgeons, conceived
the idea of AMREF
• Sir Michael Wood and Dr. Thomas Rees - first plastic
surgeons to work in Kenya.
• Former pupils of Mc-Indoe
Sir Miachel Wood
Dr. Thomas Rees

38. Professor Michael Mwasia Mbalu
• The Late Professor - first indigenous Kenyan to study plastic
surgery.
• 1966 – Bachelor’s degree in medicine and surgery - Makerere
University
• 1972, Prof. Mbalu went to Glasgow on a Commonwealth
scholarship for post-graduate training in surgery leading to
FRCS.
• He was then awarded an 18 month scholarship to study plastic
surgery at the University of California.
• Licensed from UCLA to practice plastic surgery.
• 1975 he returned to Kenya and was in charge of plastic surgery at the Kenyatta National
Hospital and the whole of Kenya.
• 1984 he started the Burns Unit. At the time, he was the deputy director of AMREF. The
first Operation Smile Mission to Kenya was conducted under him in the 1990s

39. • Dr. Bernard Githae was the second indigenous
Kenyan to study plastic surgery
• He trained in the USA under Dr. Bill Magee
• He is among the pioneers of the microvascular
surgery in Kenya
• He is the former Ag. Deputy Director of Clinical
Services at the Kenyatta National Hospital

40. Professor Ominde, Stanley Khainga
• 3rd indigenous Kenyan to venture into the specialty
• 1987, MBChB, UoN
• 1994, Mmed Surgery, UoN
• 1996, Lecturer, Surgery, UoN, worked closely with Professor Mbalu for 3 years
• 2004 to 2005 - W.H.O fellowship in plastic surgery at the Medical University of
Southern Africa(MEDUNSA), Pretoria
• 2004 - Certificate of micro-vascular surgery in plastic and reconstructive
surgery
• Positions held - Chairman of the Prof Pratt Foundation Kenyan Chapter,
Chairman of IPRAS, Coordinator Healing the Children Plastic and
Reconstructive Project Kenya, Chairman of the Multidisciplinary Committee
for Head and Neck Reconstructive Surgery at KNH and Chairman Kenya Society
of Micro-vascular Surgeons

41. Involved in
• Development of master’s program in Plastic and Reconstructive Surgery
• Annual training in micro-vascular surgery under Prof Pratt Foundation
• Setting up of pedicle and micro-vascular flaps labs at the human anatomy
department University of Nairobi.
• Involved in writing a practical teaching manual for micro-vascular surgery
• A teaching manual in plastic and reconstructive surgery for undergraduates at
the University of Nairobi.
• Coordinating MOU’s in training of plastic surgeons between the University of
Nairobi and other universities such as University of Cincinnati-USA, National
University of Rwanda, University of Limpopo and University of Pretoria.
• 2006, introduced NPWT in Kenya
• Currently the thematic head of PRAS at UoN.
• Indeed, ‘the father of plastic surgery in Kenya’

42. Expatriate contributions
• 1980 - Dr. Ismail Aref, an Egyptian expatriate.
• Worked at KNH, taught undergraduates and postgraduates at
UoN.
• In the late 1990s he started the surgical procedure reduction
mammoplasty.
• Currently retired into private practice and remains a great
teacher and mentor to many.
• Others,
• Dr. Mohamed Abdul Haq
• Dr. Makram Ghali
• Dr. Banjara.

43. The role of the University of Nairobi and Kenyatta
National Hospital
• The University of Nairobi (UON) and Kenyatta National Hospital
(KNH) have played a crucial role in the growth of plastic surgery in
Kenya.
• The UoN Medical school, based at KNH, started the plastic surgery
postgraduate training program in 2013 and recruited students, some
of whom were in their third year of study in surgery.
• It is a regional training program currently with residents from
Tanzania (1), Uganda (1 graduated), Zimbabwe (3), Cameroon (1)
and Zambia(1 recently graduated).

44. The role of the University of Nairobi and Kenyatta
National Hospital
• World class training
• Plastic surgeons from around the world visit to give lectures
• Mutual exchange of knowledge and skills local surgeons
• Collaborations with Hedelberg University - craniofacial surgery
training for residents.
• Lecturers from Toure University also visit the department and
train more on aesthetic surgeries by giving lectures and
performing surgeries.

45. The role of the University of Nairobi and Kenyatta
National Hospital
• The pioneer students are Dr. Peter Biribwa who graduated in 2016
and Dr. Faith Karanja 2017.
• 2018 – 1
• 2019 - 4
• 2020 – 2
• 2020, 25 plastic surgeons in the country serving a population of
53,771,296 (2020 midyear projections)

46. Evolution of the surgeries performed in Kenya
• At par with the rest of the world in terms of reconstructive surgery, aesthetic
surgery and research
• Reconstructive surgery including breast reconstruction,
trauma,
cleft lip and palate repair,
lower limb and ear reconstruction,
craniofacial and hand surgeries.
• Late 1990’s, Dr. Aref – Started reduction mammoplasty.
• Initially the popular technique - inferior pedicle technique using the inverted T
incision
• Later, the superomedial pedicle with the vertical scar technique got popular
• Inferior pedicle technique is still being used for the large breasts. It’s reliable for
both its viability and retention of sensation.

47. Evolution of the surgeries performed in Kenya
• 2005, at KNH, Dr. Githae, Prof. Khainga assisted by an American
surgeon - The first free flap was for the radial forearm.
• 2006, Dr. Githae, Prof. Khainga, Dr. Tanga and Dr. Kahoro – The
second free flap, on Ca Larynx patient.
• The success rate is now at 90% - compares fairly well with the
world

48. Milestones
• 2016 November - Separation of conjoined twins (sacropagus) –
MDT team plastic surgeons, neurosurgeons and pediatric
surgeons among others
• 2018 January - Hand re-implantation in a 17 yo M: MDT
consisting of 15 specialists led by Professor Stanley Khainga
and Dr. Ferdinand Nangole
• 2018 March - Foot re-implantation in a 31 yo M, by a
multidisciplinary team led by Professor Stanley Khainga and Dr.
Ferdinand Nangole
• 2019 January - Penile reimplantation of a 16 yo M at KNH by a
MDT lead by Professor Khainga and Dr Nangole

49. On November 2, 2016, Favour and Blessing, who were born conjoined, were separated at Kenyatta National
Hospital (KNH) in a surgical procedure that took more than 50 medical experts and 23 hours to complete.

50. First foot replant surgery at Nairobi Coptic Hospital in Kenya as well as in East Africa.

52. Aesthetic surgeries
• Face lifts
• Neck lift
• Rhinoplasty
• Cheek augmentation
• Breast reduction and augmentation
• Breast lift
• Abdominoplasty
• Liposuction
• Hip and buttock enhancement
• Hair transplants
• Botox injections and filler injections

53. Free tissue transfer

57. Future of Plastic surgery in Kenya
• Very promising
• Stem cell based therapies - The Plastic Surgery department,
Obs&Gyn department and KAVI.
• Advances in stem cell research, breakthrough in transitional stem
cell therapy and regenerative medicine.
• Plan? Stem cell harvest and Stem cell bank in the country.
• Professor Khainga and Dr. Biribwa pioneered a study on chronic
wound management using fat stem cells.
• Make Kenya a center for excellence in plastic and aesthetic surgery.
• To have world class, up to date aesthetic surgery performed in
Kenya.

58. New Frontiers?
• Aesthetic Surgery – room for exploration
• 3D Printing – tissues e.g. Skin,
• Robotic Surgery
• Supermicrosurgery

60. Professional Societies in Kenya
• The Kenya Society of Plastic, Reconstructive and Aesthetic Surgeons (KSPRAS).
Registered on 10th November, 2006.
1st Chairman - Dr. B. Githae 1st patron Dr AP Landra
2nd Chairman - Professor Khainga
Mission - to uplift the standard of practice in the field of plastic surgery in Kenya and
Sub Saharan Africa at large.
National Burns Centre
Sub-Saharan institute of plastic surgery
Collaborative Master in Plastic Surgery training venture with Egypt, the University of
Nairobi and the Aga Khan University Teaching Hospital, Nairobi.
2015 - International scientific conferences
2010 - Hosted the 1st Pan African plastic, reconstructive and Aesthetic conference
Member of IPRAS

62. Professional Societies in Kenya
• Wound Care Society of Kenya
Founded in 2012,
Multi-disciplinary, non-profit association
Chair – Dr Nangole
• Burns Society of Kenya (BSK)

63. Burns Society of Kenya (BSK)

64. The mural; Plastic and Reconstructive Surgery: History and Philosophy
Dr. Jose Guerrerosantos and Mexican-muralist Guillermo Chavez Vega, On the alley’s main
entrance of the Jalisco Reconstructive Surgery Institute, Mexico.

65. References
1. Valdas Macionis, History of plastic surgery: art, philosophy, and
rhinoplasty, Journal of Plastic, Reconstructive & Aesthetic Surgery
(2018), https://doi.org/10.1016/j.bjps.2018.03.001.
2. Geoffrey Gurtner, Peter Neligan, Plastic surgery. Volume 1,
Principles, 4th Edition, Chapter 2.
3. Bullivant, E., 2007. A brief history of plastic surgery. BMJ 335.
https://doi.org/10.1136/sbmj.0712462
4. Isabella C. Mazzola, Riccardo F. Mazzola, History of Reconstructive
Rhinoplasty
5. Ménard S. An Unknown Renaissance Portrait of Tagliacozzi (1545-
1599), the Founder of Plastic Surgery. Plast Reconstr Surg Glob
Open. 2019 Jan 4;7(1):e2006. doi: 10.1097

66. 6. https://medicalboard.co.ke/online-services/online-retention-registers/
7. Waithaka A.W, Khainga S.O, Aref. I, Wanjeri K, Muoki A; THE HISTORY OF
PLASTIC SURGERY IN KENYA.
8. Our History AMREF Available: http://amref.org/about-us/our-history
[June 14th 2016]
9. Kenya Society of Plastic Reconstructive and Aesthetic surgery Overview
http://kspras.com/#overview [June 5th 2016
10. David Tolhurst, Pioneers in Plastic Surgery
11. Mckoy Rolling, Faces From the Front: World War I Soldiers’ Horrific
Facial Injuries
12. East African Orthopaedic Journal, History of Orthopedics in Kenya
13. Da Vinci Medical Group
14. KAVI