Millard's first 12 principles fell under the framework of "Preparational Principles"-that is, principles to maintain in mind before making the opening incision.
The first principle was to "correct the order of priorities." Applied broadly, this could mean emphasizing integrity and ethics; it could mean prioritizing function over form; and it could also mean performing a blepharoplasty before a facelift since the latter could affect the former but not vice versa. The bottom line was that whether in life or in a particular process, each part needed to be considered in the context of the entire.
The second principle was that "aptitude should determine specialization," meaning that the plastic surgeon ought to play to strengths when deciding whether to focus on reconstructive surgery, cosmetic surgery, microvascular surgery, craniofacial surgery, head and neck oncology, hand surgery, burn physiology or laboratory research.
Millard emphasized that a person who initially appeared inept in one region could later progress to excel above all others in the exact same region. Using himself as an example, Millard revealed that he took an aptitude test early in his career that determined that he could be well-suited to writing and possibly medicine, but completely unsuited for surgery due to a perceived inability to visualize objects in three dimensions.
Despite this, he went on to become one of the most accomplished plastic surgeons in history, known particularly for the three-dimensional rotation-advancement flap that is the standard of care for cleft lip repair these days.
The third principle was to "mobilize auxiliary capabilities." That would be to say, the plastic surgeon should incorporate individual talents to develop a "personal style with individual flair." Advised to develop one primary capability and a number of secondary talents such as sculpture, music, writing or painting, the ideal plastic surgeon could be multi-talented for maximal depth and versatility in the operating room.
The fourth principle was to "acknowledge your limitations so as to do no harm," a self-evident principle that spoke to the temptation to persevere on a case with endless complications. Instead, the effective surgeon should know when to stop.
The flip side of this was the fifth principle, which was to "extend your abilities to do probably the most great." This spoke to the moral obligation to make use of plastic surgical training to alleviate human suffering, that is, to reconstruct mutilated or severely deformed patients instead of limiting one's practice to purely aesthetic procedures.
The sixth principle was to "seek insight into the patient's accurate desires." Delving into the psyche, this principle directed the plastic surgeon to decipher a patient's actual problems instead of merely taking the stated issue at face value to preempt patient disappointment, improve public relations and prevent postoperative legal complications.
The seventh principle was to "have a objective along with a dream." In plastic surgery, this principle shifted depending on whether a procedure was primarily cosmetic, in which the objective would be to surpass regular, or primarily reconstructive, in which the objective would be to attain normal. Either way, the plastic surgeon should have a target in mind before beginning an operation.
The eighth principle was to "know the perfect beautiful regular." While this perfect beautiful regular could vary among various ethnic backgrounds, it was important for the plastic surgeon to be able to define it in order to attain pleasing aesthetic proportions and visual harmony.
The ninth principle was to "be familiar with the literature." Knowing what had already been described assisted a surgeon in discriminating between procedures that would and would not be effective; it also gave the surgeon access to a collective bank of experience that allowed extension beyond what one person could accrue in a lifetime.
The tenth principle, to "keep an accurate record," was like the sixth principle in that its underlying purpose was both to further patient care and offer legal protection for the surgeon. In addition, since memory was inherently unreliable, accurate written and photographic records provided baseline references that allowed the plastic surgeon to coordinate multi-staged procedures to achieve a successful final result.
The eleventh principle was to "attend to physical condition and comfort of position." Frequently overlooked by single-minded surgeons, the basis of this principle was the belief that the optimal surgical performance depended upon great physical condition along with a comfortable working position for the surgeon.
Finally, the twelfth principle, "do not underestimate the enemy," acknowledged that peril lay behind every process. Thus, whether the enemy was hypertrophic scar formation or inadequate vascular supply, it was by no means possible to be overly vigilant in preventing surgical complications.
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