This title describes our Interplast experiences in the Pacific, organised under the College umbrella with contributions from Rotary International, another College benefit. Former plastic surgeons, Sir Benjamin Rank and Professor Don Marshall were instrumental in orchestrating these humanitarian aspects in the Melanesian ring in the Pacific. Yes, the College’s contribution is invaluable.  

Volcanic eruptions keep surfacing as detailed on recent SBS programs. This stimulated me to recount one of our experiences on Tanna in Vanuatu. Volcanos have been around forever and a day, stretching back to the Roman god, Vulcan, and even touching on the Hawaiian goddess Pele, which links the Vesuvius eruption of 79CE. Dormant volcanoes reflect nature’s control and who and when caused the eruption will take science many years to elucidate, and the press is presently full of such events.  

Our volunteer Interplast team of theatre sister Brenda Linsell, plastic surgeon Dr Julian Peters, and anaesthetist, Dr Warren Saunders had a rare moment of relaxation one afternoon visiting the Mount Yasur volcano there. We were warned to keep a discreet distance as a month before a Japanese tourist had been killed by a hot lava explosion.  

One surgical case because of its clinical applications was unique becoming the genesis of new clinical observations in the resolution of oedema using the Keystone reconstructive concept and will have ongoing clinical significance. And as for a speedy execution it sure beats 10/0 nylon over 10 hours.  

Typical Tanna locals illustrating their basic lifestyle (pictured here), not dissimilar to the patient we operated on with a scar contracture of her popliteal fossa caused by a burn 10 years earlier. 
She had a sad upbringing, could not walk easily and could not enjoy the lifestyle of a child, to the mother’s consternation. She walked with a limp and was unable to extend the knee fully.

Nature healed the wound with granulation tissue, which became the basis of the excessive scar contracture, restricting her joint movement.  

The operating theatre at Tanna was a galvanised shed, in stark contrast to the luxury we have in modern teaching hospitals in the capital cities.   

The anaesthetic team using portable equipment had the expertise to allow us to rotate the patient into the prone position so we had direct access to the popliteal fossa for scar excision.

Traditionally, a skin grafting would have been the normal clinical solution to the problem. I said to Julian Peters, my assistant surgeon, how I planned to rotate a Keystone island flap using the fascia of the calf musculature the size of one’s palm and rotating it on the pes anserinus microperforators. The circulation was intact, it hypervascularised the flap—a characteristic of the Keystone—and allowed us to cover the wound and achieve sound wound healing. 

Doing the dressings the following morning with Brenda Linsell’s assistance, there was no marginal necrosis and the wound was healing satisfactorily, with full resolution of leg oedema she had sustained for years.   

It reminded me of the Dr Edward Jenner experience who observed that the milkmaids in the cowsheds had developed immunity to the ravages of smallpox, killing millions in Europe at the time. He concluded this cow contact was the basis of their vaccination and immunity cover.   Leonardo da Vinci is reputed to have once said and rephrased by Einstein later—experience is the best form of knowledge. Professor William Osler approached all his medical problems with the same mental inclination.  

In my recent publication with Springer Nature on the use of the Keystone in complex orthopaedic problems, I included three cases repeating this observational finding. The Keystone has an effect, like a sympathectomy, to increase blood flow. It helps to correlate this finding with possible lymphatic implications, helping with the resolution of oedema. Again, a simple observation and what a bonus applied clinically and let us not forget the French word for a cow is vache, which is the origin of the word vaccination. 

Who would have thought this simple case in the middle of the Pacific would have sparked my observational instincts, allowing me to apply this surgically at the orthopaedic unit at the Western Hospital in resolving oedema, repeating the observation. Success breeds success.

So, I say this, it was a fortunate break, a lucky clinical observation with no complications when we were operating really in such a primitive hospital environment—hence the title—Operating in the Garden of Eden. 

The child’s mother was ecstatic when she saw her little girl, now a teenager, almost cured after years of stunted growth. Her embrace touched my heart when she cried on my shoulder—a reward for surgical expertise thanks to Interplast and the College.  

This reinforces the Harvard publication on the psychological satisfaction of selflessness when acting in an altruistic manner when dollars do not enter into the equation.