The History of Craniofacial Plastic Surgery and Modern-Day Pediatric Craniofacial Reconstruction-Juniper Publishers
Juniper Publishers-Journal of Pediatrics
Abstract
The discipline of reconstructive craniofacial
plastic surgery was formally developed in 1967 at The Fourth
International Congress of Plastic and Reconstructive Surgery in Rome,
Italy. It was here that the French plastic surgeon Paul Tessier, MD,
FACS presented to his colleagues the concept of pediatric craniofacial
surgery as a major surgical discipline. This meeting laid the foundation
for this surgical specialty and led to the founding of the
International Society of Craniomaxillo facial Surgery in 1983. The
discipline has continued to grow rapidly ever since with more and more
innovative operations being described routinely. Interestingly, despite
these more recent official meetings and founding societies, craniofacial
reconstruction has been practiced for centuries.
Keywords: Pediatric; Craniofacial Surgery; Reconstruction; HistoryMini Review
There is much evidence that as early as 10,000 B.C.
ancient humans practiced trephination (or the drilling of holes) of the
cranial vault. At a burial site dated to 6500 B.C. in France, 40 out of
120 prehistoric skulls were found to have holes from trephination
procedures [1]. This procedure has been performed throughout much of
recorded time and continues today as a method by which to reduce
intracranial pressure. While surgical procedures of the cranial skeleton
were occasionally performed in ancient times, more frequently
reconstructive craniofacial procedures of the soft tissues such as the
nose or ears were performed.
Sushruta, an Indian medical practitioner, described
operations for reconstructing the nose and the earlobes in the year 600
B.C.[2]. In India during Sushruta’s time, it was common practice for
criminals and war captives to have their noses amputated because the
nose was considered as a symbol of reputation and respect. Thus, a group
of potters known as the Koomas developed nasal reconstruction to help
remedy this problem [3]. His method involved using flaps from the cheek
and forehead that are still staples of reconstruction of nasal
deformities to this day.
During the Roman Empire, surgeon Paulus Aengineta
(625 to 690 A.D.) described techniques for correcting nasal deformities
and fractures of the mandible. His procedures were groundbreaking at the
time and have proven to be instrumental in the history of plastic
surgery [4].
The Renaissance (14th to 17th centuries) was a time
relatively devoid of adavancements in craniofacial plastic surgery.
However during this time there was one standout physician who many
consider the father of modern plastic surgery: GaspareTagliacozzi
(1545-1599) of Bologna.He also specialized in reconstruction of the nose
and detailed his approaches in his 1597 publication entitled, “De
CurtorumChirurgia per Insitionem”. For soft-tissue nasal reconstruction,
he described the elevation of a pedicledbicipital arm flap, attachment
of the flap to the nasal deformity, 14 days of immobilization of the arm
attached to the face, and subsequent division and inset of the flap
from the arm [5]. It was, of course, Tagliacozzi who in 1597 penned the
most infamous phrase in plastic surgery: “We restore, repair, and make
whole those parts…which nature has given but which fortune has taken
away, not so much that they may delight the eye but that they may buoy
up the spirit and help the mind of the afflicted.”
Joseph Carpue, in October of 1814, described a method
for nasal reconstruction using a forehead rotation advancement flap as
Sushruta and the Koomas had been performing for centuries in India.
Around that same time, in 1845, Dieffenbach described the usefulness of
secondary rhinoplasty procedures to correct and refine the shape of the
nose after the first procedure [6]. Following Dieffenbach, von
Langenbeck made major contributions to the modern approaches for
correcting congenital cleft lip/palate and jaw deformities. Advancements
in correcting pediatric craniofacial abnormalities was more recently
advanced by plastic surgeons such as Joseph McCarthy, Court Cutting,
Ralph Millard and Paul Tessier. The majority of reconstructive
craniofacial surgery prior to 1914 was focused on the soft tissues of
the face. However, trench warfare during World War I changed everything
and redefined the
world of plastic surgery.
Craniomaxillo facial injuries during the First World War were
remarkable in both number and extent of damage. Prior to World
War I, there were very few practicing plastic surgeons in general,
and almost none who were capable of handling the appalling
damage suffered by war veterans. Furthermore, many of the
veterans were presenting with gunshot wounds to the face and
cranial skeleton and few surgeons specialized in the craniomaxillo
facial skeleton other than surgeons whose interests were in
pediatric cleft lip and palate [7]. Because of this, both the United
States and France set up specialized medical centers on military
bases to manage patients who had been facially mutilated. It took
just a few years before plastic surgeons were learning how to
appropriately manage these injuries; in 1921, Blair published his
important paper: “Reconstructive surgery of the face” [8]. Many
leaps and bounds were made during World War I in the arena
of maxillofacial surgery. Harold Gillies was an important plastic
surgeon who pioneered many techniques for treating individuals
with disfiguring facial injuries. With the onset of World War II,
plastic surgeons again found themselves re-inventing the specialty.
World War II presented craniofacial plastic surgeons with a
myriad of new craniofacial challenges due to advances in weaponry.
Complex fractures and displacement of the craniofacial skeleton
were common and it was here that modern skeletal craniofacial
plastic surgery was introduced. In 1949, Kazanjian and Converse
published one of their most important works: “Surgical Treatment
of Facial Injuries”[9]. This was the first comprehensive paper
discussing the surgical management and intricacies of traumatic
craniofacial injuries.
In terms of modern pediatric craniofacial surgery, in addition
to soft-tissue reconstruction, plastic surgeons address all
aspects of the bony skeleton including entering the cranial vault
in craniosynostosis cases: an anatomic region previously only
violated by neurosurgeons. Since 1967, the scope of practice of the
craniofacial reconstructive surgeon has increased dramatically
and the complexity of the procedures performed has increased
similarly. Today, craniofacial surgery is performed neon tally, in
infancy and in pediatric patients as well.
Modern plastic surgeons trained in craniofacial reconstruction
perform many reconstructive operations on young patients
including mandibular distraction and reconstruction, Le Fort
distractions, maxilla mandibular advancement, ear reconstruction
for microtia, rhinoplasty and others. Additionally, craniofacial
surgeons help correct defects in trauma patients, pediatric
patients diagnosed with craniosynostosis, cleft lip and/or palate,
micrognathia, mandibular retrognathism, hemifacialmicrosomia,
mandibular prognathism, Teacher Collins Syndrome, Crouzon
Syndrome and others. While these lists are nowhere near
exhaustive, they are presented to demonstrate the dynamic field
that is pediatric craniofacial plastic surgery and the incredible
advancements in surgical technique that have evolved throughout history.
Currently, high-resolution prenatal ultrasound technology is
making the diagnosis of pediatric craniofacial abnormalities not
only more efficacious, but also diagnoses are being made earlier
during pregnancy. This is important for many reasons. First of all,
early diagnosis can help with family planning, genetic counseling
and education of parents by obstetricians and pediatricians at
an earlier time. This may be psychosocially helpful for parents
and allow them to prepare and potentially reduce distress at the
time of birth. Perhaps more importantly, antenatal diagnosis of
conditions such as Pierre-Robin Sequence can be better prepared
for ahead of time. Severeglossoptosis and/or retrognathism can
cause lethal respiratory compromise at time of birth, and the highrisk
pediatric and airway teams can be notified ahead of time.
Another exciting aspect of earlier, prenatal diagnoses
of pediatric craniofacial abnormalities is the possibility for
intrauterine surgery. In recent years, the use of intrauterine
surgery for craniofacial malformations has been successfully
utilized many times. The conditions that have been addressed
most commonly in utero are cleft lip/palate operations and
occasionally simple Tessier facial clefts. The intricacy of these
operations leads to scar-less repairs of the cleft palate and or
lip, for example. This is important because repair of cleft palates
often lead to palatal scarring which frequently results in mid face
growth restriction as the pediatric patient develops. This leads to
the necessity for maxillary advancement in the future. In utero
repair without scarring can reduce the need for multiple future
surgeries including for mid face growth restriction, secondary
alveolar clefts and perhaps ore nasal fistula formation.
Pediatric craniofacial abnormalities can be very distressing
for both the parents and the child as he/she grows. Pediatricians
and neonatologists alike can make a great impact for children and
their families for the life of the children and this impact can be
profound. Fortunately, as an adjunct, plastic surgeons trained in
pediatric craniofacial surgery can make remarkable, life-changing,
interventions for these children and families.
It is important to mention briefly that certain craniofacial
malformations such as Teacher-Collins Syndrome with multiple
skeletal and soft-tissue disfigurements may be treated with
microsurgery and even facial transplantation in the future. It is
important to note that facial all o grafts in children have not been
described in the literature and obviously finding families willing to
donate a brain-dead pediatric donor face is wrought with its own
ethical concerns. However, it is a possibility that likely will take
place one day and may revolutionize the future of the management
of children with complicated craniofacial abnormalities. With the
remarkable rate that technology is advancing, the future certainly
will again refine and redefine craniofacial pediatric surgery and
plastic surgeons will undoubtedly lead the way in traversing that
path in multi-disciplinary cooperation with pediatricians and
neonatologists.
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