British Journal of Plastic Surgery (1977), 30, 255-260

GUSTAV SIMON (1824-1876): SIMONART OF THE BAND?

By T. GIBSON, D.Sc., F.R.C.S., F.R.S.E. Glasgow and West of Scotland Regional Plastic and Oral Surgery Unit, Canniesburn Hospital,

Bearsden, Glasgow G6r IQL

EVERY well-informed plastic surgical trainee knows that Simonart’s name is applied to the band of tissue which bridges an incomplete cleft of the lip. My interest in him was aroused when a paper was submitted to the Journal with his name spelt “Simmonart”. While checking the spelling in the immediately available literature, I was intrigued to find that Millard (1964) spelt him “Simonart” while Holdsworth in the 3rd edition of his “Cleft Lip and Palate” (1963) had “Simonarts” and in the 4th edition (1970) “Simonartz”. Neither gave any reference to him.

A more intensive study of the recent literature revealed that virtually all the references to him and his band could be traced back directly or indirectly to Holdsworth or Millard. Prior to them, he was nowhere to be found. Neither Veau nor Axhausen mentioned him. He was not in Garrison and Morton, nor the catalogues of the Surgeon General’s Library, nor Callisen. Hirsch’s Biographisches Lexikon (x887), which gives short biographies of almost every doctor up to about 1884, did not list Simonart but revealed a German surgeon Gustav Simon and a reference to a paper written by him on cleft palates in 1864. Miss E. Wilson, one of the librarians in the Royal College of Physicians and Surgeons of Glasgow reasoned that this might be the man and that somewhere in the German Literature there was a reference to the bands of “Simon Arzt in Restock”; “ Arzt”, of course, means doctor. It seemed a long shot, but a search was instituted through the International Section of the British Lending Library at Boston Spa.

This Simon is in fact frequently quoted in the literature of bilateral cleft lip (e.g. Grabb et al., 1971) as the first to show that the premaxilla need not be excised or forcibly thrust backwards since it will move slowly backwards when the lip segments are united to the prolabium. The reference invariably given for this information is that mentioned above on cleft palate “Ueber die Uranoplastik”. It took many months to obtain this article and then it was obvious that this was one of those references copied from one paper to another and never checked. It was entirely devoted to cleft palate and mentioned nothing about cleft lips or the premaxilla.

This might have been the end of the trail, but by a strange serendipity, during the hunt for “Ueber die Uranoplastik”, the Library of the Royal Academy in Prague, apparently because they did not have a copy, forwarded instead a book by Simon dated 1868 in which there is a long chapter on “Uranoplastik”. The title of this book, which may be roughly translated as “Annals of the Surgical Clinic of Restock Hospital for the years 1861-1865”, gave no indication that it was concerned with cleft surgery. The first section was entitled “Descriptions of interesting cases” and even the title of the second section “Contributions to plastic surgery, mainly about plastic operations to the walls of accessible body cavities: mouth, vagina and rectum” did not sound particularly promising. When the pages were opened, however, it was obvious that this was the source of the bands of Simon Arzt.

The illustrations speak for themselves. Simon had had some success in closing bilateral clefts particularly if they were incomplete or the premaxilla was not too far

255

256 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. I. (a) and (b) Closing a bilateral cleft with a small prolabium which is trimmed to a wedge shape. Simon wrote that the cheek incisions at a should run more horizontally. (c) and (d) When the prolabium is

larger it is cut to a rectangular shape.

GUSTAV SIMON: SIMONART OF THE BAND? 257

FIG. 2. The alar base flaps. The skin from the alar base is sutured to the prolabium. The cleft margins are intact.

forward (Fig. I). He trimmed the prolabium to either a wedge or a rectangular shape depending on the tissue available and approximated the lateral elements as shown after mobilising them by full thickness “wavy” incisions passing laterally into the cheeks. However, when he tried this on an &day-old child whose premaxilla was hanging from the tip of his nose, the tension was too great and the wounds ruptured. The child died some weeks later of “marasmus”.

When he next had a similar case he did not attempt to bring the cleft margins together but devised the “alar base flaps” shown in Figure 2 and, after rotation- advancement, sutured the skin from the alar base to the prolabium. This child was then g months old, and IO weeks after the operation the premaxilla had moved right back into the alveolar defect, Simon closed the remaining defect between the cleft margins in his usual way.

His next case in which the premaxilla was at the tip of the nose was a r-year-old boy. The left cleft was the widest and only it had an alar base flap brought across at the first operation (Fig. 3). During the following weeks, Simon resolved in future always to deal with both sides at the first operation unless the patient’s condition forbade it because the premaxilla was pulled progressively across to the left and the right cleft, which he still had to bridge, was growing wider and wider. However, 6 weeks after the first operation he successfully rotated and advanced an alar base flap across it. Four months later the premaxilla was symmetrical again and had moved backwards g mm to the margin of the alveolar defect (Fig. 4). The secondary defects had closed and he was impressed by the broadening of the prolabium from 6 to IO mm.

He waited a further IO months before completing the repair (Fig. 5). He noted that the premaxilla had been unable to enter the defect in the alveolus because the lateral palatal segments had closed behind it.

258 BRITISH JOURNAL OF PLASTIC SURGERY

0 3a

FIG. 3. (a) and (b) Lateral view of the alar base flap being rotated and advanced to the prolabium.

DISCUSSION

Gustav Simon was a famous surgeon in an era when the discovery of anaesthesia had opened up undreamed of fields of activity. In his early days he contributed much to the treatment of vesico-vaginal and recta-vaginal fistulas and regarded clefts of the lip and palate as similar fistulas to be dealt with by similar techniques. This is why he lumped together mouth, vagina and rectum in the second section of his book. His writings on his plastic surgical operations make fascinating reading and deserve a much fuller historical treatment than is possible here. The important point in our search for Simonart is that they have been virtually lost from the literature of plastic surgery because he chose to publish them in a book with a general title which gave no inkling of its contents. That is fact; the rest is speculation.

That the premaxilla could be moved backwards so painlessly and bloodlessly by creating bands across each cleft must have been welcome news to others who dealt with these difficult cases and his name and technique would be known to his contemporaries and probably the next immediate generation. Then 2 things happened:

Someone who wrote a paper on bilateral clefts knew about and wrote about Simon’s contribution, looked up his published works (e.g. in Hirsch), could iind only one on cleft surgery, decided without looking that that must be it, and gave as the reference “Ueber die Uranoplastik” which has been copied from article to article ever since.

Secondly, someone wrote a similar paper about the retropositioning of the pre- maxilla by creating the transverse bands of “Simon Arzt in Restock”. In the 1950’s

h4r William J. Holdsworth and Dr D. Ralph Millard were both working in the late Sir Harold Gillies’ Unit in Basingstoke, England, and Mr Holdsworth had read widely in cleft lip and palate literature for his popular textbook. Is this where it all began? The “z” which appears in the 4th edition of Holdsworth almost confirms that it is. I have

GUSTAV SIMON: SIMONART OF THE BAND? 259

FIG. 4. (a) and (b) The appearance of the lip 4 months after bridging the clefts with the naso-labial flaps. Are these the “bands” of Simonart(

FIG. 5. The cleft margins have been opened up and advanced below the naso-labial flaps. (Free-hand sketch of the fully healed lip.)

written to both, but Mr Holdsworth is now retired and has disposed of his papers and Dr Millard has replied that he too is trying to track “Simonart” but had no information to add.

This is a sort of bibliographical whodunnit and I feel certain that the solution given above is correct. The clincher would be the discovery of a paper in German on cleft lips with the term “Simon Arzt”. I have looked in a desultory fashion without success. Should someone produce a real, alive or dead, Simonart I will grovel and print an immediate retraction.

One final point: Simon’s bands were created by operation. What should we call the naturally occurring bands if no Simonart exists?

260 BRITISH JOURNAL OF PLASTIC SURGERY

SUMMARY

Gustav Simon was the first to describe how, in a bilateral hare lip, the premaxilla would move backwards when the clefts were closed.

The reference invariably given for this is wrong. The “bands” which Simon Arzt created to bridge the clefts and pull back the

premaxilla are almost certainly the origin of the term “Simonart’s band.

I am grateful to Mrs Nancy Gelleburn and Miss E. Wilson for their help in seeking the original papers and for the permission of Mr William J. Holdsworth and Dr D. Ralph MillardJr., to publish my references to them.

REFERENCES

GRABB, W. C., ROSENSTEIN, S. W. and BZOCH, K. R. (1971). “Cleft Lip and Palate.” Boston: Little Brown and Company.

HIRSCH, A. (1887). “Biographisches Lexicon der hervorragenden Aerzte aller Zeiten und VBlker.” Wien and Leipzig: Urban and Schwarzenberg.

HOLDSWORTH, W. G. (1963). “Cleft Lip and Palate”, 3rd Edition. London: William Heinemann, Medical Books, Ltd.

HOLDSWORTH, W. G. (1970). “Cleft Lip and Palate”, 4th Edition. London: William Heinemann, Medical Books, Ltd.

MILLARD, D. R. (1964). Refinements in rotation advancement cleft lip technique. Plastic and Reconstructive Surgery, 33, 26.

SIMON, G. (1864). Ueber die Uranoplastik mit besonderer Beriicksichtigung der Mittel zur Wiederherstellung einer reinen (nicht niiselnden) Sprache. Greifswalder Medicinische Beitrage, a, 129.

SIMON, G. (1868). “Mittheilungen aus der chirurgischen Klinik des Restocker Kranken- hauses wlhrend der Jahre 1861-1865.” Prag: Verlag von Carl Reichenecker.