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Ink: the first incision - planning a plastic surgical operation
Of all surgical disciplines, plastic surgery demands the greatest degree of innovation to effectively address the conditions it seeks to correct. Plastic surgery is the only specialty where the “first incision” is made in ink, and it is often the most important one.
Drawing as surgical art
Of all surgical disciplines, plastic surgery demands the greatest degree of innovation to effectively address the conditions it seeks to correct.
The act of marking the body before surgery is often overlooked, but it is a key example of where medicine and art intersect. Just as Leonardo da Vinci used ink to understand the human body, plastic surgeons use it to reshape it, drawing with an anatomical and aesthetic eye. The skill lies not only in where to cut but in knowing how tissue will move, stretch, and scar. This understanding is both scientific and intuitive.
Plastic surgery is the only specialty where the “first incision” is made in ink, and it is often the most important one.
Mapping the human canvas
Every plastic surgical operation begins with an assessment: what tissues are missing, what will be lost during surgery, and what remains available for reconstruction. The surgeon must then decide whether a local repair using adjacent skin and tissue can be used or whether tissue must be transferred from elsewhere.
The practice of marking the body with ink for plastic surgery was first described in 1460 by Heinrich von Pfolspeundt, a German surgeon who recorded the details of a rhinoplastic procedure performed by Antonio Branca, an Italian surgeon. He described planning the incisions for an upper arm pedicled flap using ink painted around a leather or parchment template of a nasal defect. This was again described in 1597 by Tagliacozzi, who used ink to mark the incision lines.
For local flaps, the planning is done directly on the patient’s skin. This isn’t just a technical necessity but a foundational act of creativity. Sir Harold Gillies, the father of modern plastic surgery, once remarked that "the drawing of the flap outline is the first incision.” This sentiment still rings true today. The lines drawn on the skin are not mere guides, they are the earliest steps in reshaping the human form.
At Middlemore Hospital in Auckland in the 1960s, plastic surgical teams used Bonney’s Blue ink and a fine mapping pen to make these marks.
By the 1970s, disposable skin markers became standard, but the practice remains unchanged in essence: an operation begins with drawing.
Three dimensions
While superficial examination shows only the two-dimensional surface, plastic surgeons must also anticipate depth. A flap must not only cover a defect, it must recreate volume and contour, especially on the face. This is where an understanding of light, shadow, and form, classical concerns of artists guides surgical planning.
Scars
Every plastic surgical plan must account for the scars it will leave behind. Scarring varies depending on genetics, skin type, incision placement, and how tension is distributed during closure. While some scars are inevitable, planning can reduce their prominence, for example on the face placing surgical incisions in natural wrinkle lines, folds, or junctions where they are less visible.
Scar maturation can take up to a year, and numbness near the incision often persists as nerves regenerate. Surgeons must plan not just for the immediate closure, but for how the tissue will look, feel, and behave over time.
While every effort is made to minimise surgical scarring abnormal scars can occur. These include:
- Keloid scars extend beyond the original wound.
- Hypertrophic scars remain raised but within the wound borders.
- Sunken scars occur when deep tissue is lost.
An Auckland discovery: the role of the circle technique in surgical planning
Understanding how the skin stretches and moves is crucial in minimising scarring. An Auckland plastic surgeon discovered a key technique for optimum scar lines. In 1979, Dr Michael H. Flint, plastic surgeon and researcher in the Department of Surgery, School of Medicine, The University of Auckland, described his technique for determining the best incision lines for acceptable scarring. He found that the placement of the original incision is the most important single factor for achieving optimal wound healing.
Flint introduced the "Circle" technique to map the natural tension lines of the skin. Serendipitously he observed that imprinted circles of 1–2 cm diameter, using a simple inked rubber stamp, on the trunk and limbs of a person in the flexed foetal position, deformed into ellipses when the subject resumed the anatomical unflexed position. The long axes of these ellipses are aligned with the direction of skin tension. The circles allow surgeons to plan incisions that align with skin tension lines, warn of potential wound closure difficulties, and reduce the risk of wide or stretched scars.
The Middlemore Hospital plastic surgery unit team had the privilege of being the first plastic surgeons to hear about this technique from Michael Flint in person, prior to its publication.
Planning in reverse
In more complex cases, where the defect is remote from the repair site, plastic surgeons in New Zealand and internationally employ a technique called “Planning in reverse.” A pattern of the defect made from oiled silk or other material is applied to the donor site. The tissue is then outlined to match the surgical defect. This method dates back centuries, with some of the earliest examples coming from ancient India.
Whether it was the leaf patterns described by Sushruta in 600 BC or the wax models used in 18th-century London, surgeons have long relied on visual guides to shape and measure human tissue.
Plastic surgery is the only specialty where the “first incision” is made in ink, and it is often the most important one.