Dr. Wendell Hughes: Grafting Greatness.

Dr. Wendell L. Hughes (1900-1994)[1]

“There is much to be done, but each step is a nibble at the base of the mount of knowledge. The path upward is lined with many unknown obstacles, but we cannot afford to rest on our laurels,” Wendell L. Hughes

Wendell L. Hughes' life could well be described as “like for like,” just as the surgery that he is most well known for. He was a man of principles, ideas, dedication, and passion and his work reflected his personality. His life and contributions have been documented by many, including eloquent obituaries by Crowell Beard and Albert Hornblass. He is remembered every year in the Academy's annual lecture dedicated to him. It is, however, in his work that he lives on.

Dr Hughes was born on February 26, 1900 in Thorndale, Ontario, Canada. He completed his MD from the University of Western Ontario in 1922 and continued his practice at New York and Hempstead, Long Island. He was the attending Chief surgeon at New York Eye and Ear Infirmary. Post his retirement in 1968, he moved to Boca Raton, Florida, where he lived till his last day on February 10, 1994.

He trained under Dr John Martin Wheeler, the first true oculoplastic surgeon in the country, who played a vital role in developing his interest in the speciality.[1] Wheeler was the first to lead an instructional course on oculoplastic surgery at American Academy of Ophthalmology and Otolaryngology (AAOO) in the late 1920s. After his untimely death, Dr Hughes continued the instructional course with increasing audience, larger hall and longer duration with each year.[2]

He developed, documented, and established many surgical procedures. He was an educationist and taught many who went on to become leaders in oculoplasty including Byron C. Smith and Marvin H. Quickert.[3] Dr Hornblass described Hughes as a “prolific writer and outstanding lecturer. He was innovative, honest and fair. According to Dr Charles Maris, he referred ophthalmology as the 'Queen of specialities'”.[3] He was one of the first to teach key principles and surgical techniques using motion picture.[2]

He proposed a combined surgery for cataract and glaucoma in 1928 when he was severely criticized. Today it is one of the standard procedures of choice.[4] In 1932, he patented his invention, an Ophthalmotrope, which was a mechanical model of an eye to demonstrate the actions of muscles.[5]

In 1933, Dr Hughes presented his work on lower lid reconstruction technique before the Ophthalmology Section of the New York Academy of Medicine meeting.[2] This was a case report of a 65-year-old gentleman with tumor in the medial two-third of the lower lid (LL). The mass was excised, and lateral portion of the LL margin was denuded as was a similar area in the upper lid (UL) margin. These were sutured together keeping the LL stretched and cornea covered. A subcutaneous pocket was created in the UL [Fig. 1a]. A piece of mucous membrane (MM) obtained from the cheek was attached to a metal form with its smooth surface towards the plate and inserted into the pocket created such that the raw surface of MM formed adhesion with the subcutaneous tissue of the UL skin. The metal form was bent at the upper edge so that the skin edge would now be lined by the MM [Fig. 1b and c].[6] In the second stage, the granulation tissue was removed from the LL after 3 weeks to form a clean bed. The skin of the UL, lined by MM, was removed. MM was sewn to the remaining conjunctiva of LL and the skin was sutured to skin [Fig. 1d].[6] Six weeks later, the intermarginal adhesion was cut. Dr Wheeler, who was present at the meeting remarked, “this is one of the most splendid results of plastic surgery about the eye I have ever seen.” This procedure ensured a smooth MM moulding onto the lid edge, a good fornix, free movement of eyeball without adhesions between bulbar conjunctiva and skin graft with perfectly matching skin quality and texture.[6]

Figure 1

Lower lid reconstruction technique described in 1933 (a). The edges of the lids are denuded and sutured together. (b). Mucous membrane is attached to a metal form and inserted into the upper lid subcutaneous pocket. The dotted line represents the area to be harvested in the second stage. (c). The form in position. (d). Mucous membrane lined skin of upper lid is removed and sutured to reform the lower lid. (Modified from Hughes WL. Removal of the lid, with plastic repair. Arch Ophthalmol 1933;10:198-201)

In 1937, he developed the tarsoconjunctival flap, for reconstructing a defect involving more than half the LL.[7] In the first stage, the tumor was excised and the skin of the cheek was undermined to be advanced upwards without tension. The UL was split transversely along the gray line. The dissection between the two lamella was continued upwards for about 3 mm above the upper margin of tarsus without disturbing the attachment of levator to the tarsus. The lower epithelial border of tarsus was cut off [Fig. 2a]. The cut edge of the UL tarsus and conjunctiva was connected to the conjunctival margin of the inferior fornix with silk sutures. The skin from cheek was drawn up and attached to the middle of the anterior surface of the tarsus. The superficial layer of UL was attached to the anterior surface of the upper half of the tarsus. The two edges of skin were sutured [Fig. 2b]. In the second stage a transverse trough was made in the new LL skin down to the tarsus immediately below and parallel to the lashes of the UL after 6 weeks [Fig. 2c]. A strip of hair taken from the lower nasal part of the eyebrow of the opposite eye was fixed with the ends of the graft tissue reversed [Fig. 2d]. The tarsus provided a good base and the raw tissue created during the dissection of the trough gave mechanical and nutritional support to the graft. Seven weeks later, a transverse incision was made between the two rows of lashes through the skin and tarsus to open up the palpebral fissure. The novel strategy produced no additional scars, and an anatomically sound LL with preserved functions. While the technique has undergone several modifications, it has stood the test of time for over 80 years now.

Figure 2

Tarsoconjunctival flap for eyelid reconstruction. (a) Cross section showing (A) the tumor (B) the line of excision, (C) undermining of the skin to be brought upwards, and (D) the line of dissection in upper lid. (b) The final arrangement of the upper lid with the skin of cheek pulled up and attached to the tarsus of upper lid. (c) Trough dissected to transplant lashes. (d) The transplant in place with lashes directed downwards with a collodion. (Modified from Hughes WL. A new method for rebuilding a lower lid: Report of a case. Arch Ophthalmol 1937;17:1008-17)

In 1943, his thesis for American Ophthalmological Society, Reconstructive Surgery of Eyelids was published as a textbook. This was not only a ground-breaking thesis, but the most comprehensive book on ophthalmic plastic surgery during its time.[2] He dedicated his work to his mentor, Dr John Wheeler.

At the age of 3, Wendell Hughes was kicked by a horse leading to a fractured maxilla and a large facial gash. “The heavy needles and coarse sutures left permanent scarring and suture marks which would be quite unacceptable today,” he had said.[8] In 1950, Drs Hughes, J. Gordon Cole, Byron C. Smith, Albert B. Saradarian, Richard C. Troutman, Raynold N. Berke, and Louis J. Girard met with Howard Zoller, representative of Ethicon Inc. and discussed problem related to sutures and needles used in ophthalmic surgeries. This meeting, said Hughes, “sparked a profound change in needle and suture design.”[8] In 1957, the Plastic Surgery Panel was established. Their meetings led to the creation of products necessary for superior results.[28]

In 1955, he described a method for the correction of congenital palpebral phimosis with lateral canthotomy, and a a Y-V procedure, followed by LPS resection for ptosis.[9]

Dr Hughes chaired the oculoplastic section of the AAOO from 1950 to 1968 and was also the editor of the first edition of Academy's Manual of Ophthalmic Plastic Surgery. In 1967, he was elected the President of AAOO, the predecessor of the American Academy of Ophthalmology. The Wendell Hughes lecture was instituted in 1969 with the first two lectures being delivered by Alston Callahan and Byron Smith. Dr Hughes was the first President of the American Society of Ophthalmic Plastic and Reconstructive Surgery.[123]

He took active interest in the Society's tennis matches. He donated tennis medallions to the winners of women's tennis doubles for 11 years, which eventually became Hughes Bowl in 1983. He was also passionate about chess and sailing.[2]

Dr Hughes was truly the pioneer who laid down the foundation of ophthalmic plastic surgery as we know and practice today.