The History

of Maxillofacial
Surgery
An Evidence-Based Journey
Elie M. Ferneini
Michael T. Goupil
Steven Halepas
Editors

123
The History of Maxillofacial Surgery
Elie M. Ferneini • Michael T. Goupil
Steven Halepas
Editors

The History of Maxillofacial

Surgery
An Evidence-Based Journey
Editors
Elie M. Ferneini Michael T. Goupil
Greater Waterbury OMS Division of Oral & Maxillofacial Surgery
Beau Visage Med Spa Partner University of Connecticut Health Center
Cheshire, CT, USA Farmington, CT, USA

Steven Halepas
Columbia University Irving Med Center
NewYork–Presbyterian Hospital
New York, NY, USA

ISBN 978-3-030-89562-4    ISBN 978-3-030-89563-1 (eBook)

https://doi.org/10.1007/978-3-030-89563-1

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Foreword

Why write a history book, or any study of history, or of any endeavor, scientific or
otherwise? Both George Santayana (1863–1952), the philosopher and author, and
Winston Churchill (1874–1965), world leader and author, agreed on the maxim
“those who do not remember the past are condemned to repeat it.” Indeed, “the past
is prologue” —Shakespeare, The Tempest.
Let us remember that all oral facial surgical specialties had their modest origins
in the hands of medieval barber surgeons who extracted teeth, drained abscesses,
and cauterized wounds in barns and village squares without benefit of anesthesia,
asepsis, or hemostasis. Now, leave that centuries-long era of rigid dogma, profound
ignorance, and superstition and fast forward to this twenty-first century of evidence-­
based innovative and invasive techniques and technology. This book describes the
evolution in the performance of surgery and a revolution in ideas about the role of
surgical specialties who operate in the orofacial region in the spectrum of healthcare.
During this author’s clinical and academic career (1961–2019), OMS moved
from the shadowed shallows into the bright mainstream of American surgery,
despite the reefs and rocks it encountered there. This was accomplished not just
through the development and importation of new techniques but also by enhanced
education which placed us on a par with other surgical specialties. A bridge, albeit
at times a narrow one, now unites dentistry and medicine for the well-being of
patients and the continued enhancement of both professions. Surely, a basic year (or
two) of general surgery education has created technically better OMS surgeons as
well as expanded our knowledge and expertise in dealing with contemporary comor-
bidities and the emotional strains that our patients endure.
As we continue to confront the present and future frontiers of OMS, we should
also seek more knowledge of the great advances of the past in order to comprehend
the motives, struggles, perseverance, tenacity, and, yes, even the failures of those on
whose historical shoulder we stand. Mistakes have been made even in the recent past,
often resulting in a bandwagon effect, despite the present availability of evidence-­
based facts and lightning-fast electronic communication. By learning lessons from
the past perhaps we can avoid some of the pitfalls of the present. To paraphrase

v
vi Foreword

British Prime Minister Harold Macmillan (1894–1986), “the purpose of education is

so that you will know when men are talking rot.”
Our goals, the conquest of disease and deformity, are hardly yet accomplished,
but lessons learned from the past can surely be applied to the present and the trajec-
tory of the future. The History of Maxillofacial Surgery is a wonderful compilation
of our professional history. It is a well-written, enlightening, and enjoyable read.

Hartford, CT, USA Morton H. Goldberg

Preface

The following introduction was drafted by the late Dr. Laskin just a few months
before he passed. Dr. Laskin had a remarkable impact on the field of oral and maxil-
lofacial surgery. The editors would like to thank him for his dedication to our spe-
cialty and for the generation of surgeons he trained. While he was unable to see the
final version of the book, we find it only fitting we share his thoughts on the “History
of Maxillofacial Surgery.”
Maxillofacial surgery has a unique scope that is rooted in both medicine and
dentistry. Therefore, to describe its complete history in a single publication would
not allow for sufficient discussion of the most important aspects. To avoid this prob-
lem, the editors of this book have chosen to focus on those aspects that they consider
to be of greatest significance.
The 23 chapters have been divided into 3 sections: an overview of the early his-
tory of maxillofacial surgery, a discussion of the conventional procedures within its
scope, and the history of the more advanced procedures and techniques such as
management of cleft lip and palate, surgery for craniosynostosis, temporomandibu-
lar joint surgery, distraction osteogenesis, and cosmetic surgery.
To provide the most detailed and accurate information, the various chapters are
multi-authored and multi-specialty based. Moreover, in all surgical areas, the dis-
cussions are evidence based. Accompanying the text are numerous illustrations, fig-
ures, diagrams, and tables.
The editors are to be complimented for their unique approach to this complex
story. This book should not only be of interest to the different surgical professionals
who practice varying aspects of maxillofacial surgery but also to those practitioners
who refer patients for such procedures.
Richmond, VA, USA  Daniel M. Laskin

vii
Contents

Part I Early History


Saint Apollonia: Patron Saint of Dentistry����������������������������������������������������    3
Christine E. Niekrash

Anatomists: The Basis of Surgery������������������������������������������������������������������   13
Margaret A. McNulty and John A. McNulty
The Barber-Surgeons��������������������������������������������������������������������������������������   31
Michael T. Goupil

The Three Pillars of Surgery��������������������������������������������������������������������������   39
Morton H. Goldberg
Anesthesia ��������������������������������������������������������������������������������������������������������   51
Andrew R. Emery and Leonard B. Kaban

The Legacy of Maxillofacial Surgery During the Great War����������������������   71
Shahid R. Aziz and Samina H. Aziz

Formation of Head and Neck Surgical Specialties����������������������������������������   89
Gabriel M. Hayek and Michael T. Goupil

Part II Conventional Procedures


Head and Neck Infections ������������������������������������������������������������������������������ 107
Justin Fazzolari, Bridget Ferguson, and Sidney B. Eisig
Evolution of Tooth Removal���������������������������������������������������������������������������� 125
Michael T. Goupil and Vernon Burke

Dental Implants and Bone Augmentation������������������������������������������������������ 135
Steven Halepas, Kenneth MacCormac, and Elie M. Ferneini

ix
x Contents

Midface Trauma ���������������������������������������������������������������������������������������������� 157

Michael S. Forman, Joy X. Chen, Joel M. Friedman,
and Shahid R. Aziz
Mandibular Trauma���������������������������������������������������������������������������������������� 177
Carlos R. Hernandez, Daniel E. Perez, and Edward Ellis III

Part III Advanced Procedures

Orthognathic Surgery�������������������������������������������������������������������������������������� 197
Christopher S. Midtling and Timothy A. Turvey
Radiation Oncology ���������������������������������������������������������������������������������������� 241
Brett H. Diamond, Utkarsh C. Shukla, Mark H. Sueyoshi,
and Kathryn E. Huber

Head and Neck Tumor Surgery���������������������������������������������������������������������� 251
Andrew Deek and Eric R. Carlson
Surgical Flaps �������������������������������������������������������������������������������������������������� 281
Steven Halepas and Scott H. Troob
Microneurosurgery������������������������������������������������������������������������������������������ 309
Benjamin Palla, Preston Dekker, and Michael Miloro
Temporomandibular Joint Surgery���������������������������������������������������������������� 327
Kenneth Kufta, Peter D. Quinn, and Eric J. Granquist
Distraction Osteogenesis���������������������������������������������������������������������������������� 353
Dani Stanbouly and Michael Perrino
Craniosynostosis Surgery�������������������������������������������������������������������������������� 367
Jessica S. Lee and Jason W. Yu

Cleft Lip and Palate Surgery�������������������������������������������������������������������������� 391
M. Alejandro Fajardo, Derek J. Tow, Christopher Hughes,
and Charles Castiglione
Facial Cosmetic Surgery���������������������������������������������������������������������������������� 411
Keyur Naik, Pasquale G. Tolomeo, and Elie M. Ferneini

Minimally Invasive Cosmetic Procedures������������������������������������������������������ 425
Elizabeth M. Will, Brian M. Will, Michael J. Will,
and Alia Koch
Index������������������������������������������������������������������������������������������������������������������ 443
Contributors

Samina H. Aziz The Wardlaw Hartridge School, Edison, NJ, USA

Shahid R. Aziz, DMD, MD, FACS, FRCSEd Department of Oral and
Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ, USA
Vernon Burke, DMD, MD, FACS High Desert Oral & Facial Surgery, El Paso,
TX, USA
Eric R. Carlson, DMD, MD, EdM, FACS Department of Oral and Maxillofacial
Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
Charles Castiglione, MD, MBA, FACS Division of Plastic Surgery, Hartford
Hospital and Connecticut Children’s Medical Center/University of Connecticut,
Hartford, CT, USA
Joy X. Chen, DMD, MD Will Surgical Arts, Rockville, MD, USA
Andrew Deek, DDS, MD Department of Oral and Maxillofacial Surgery,
University of Tennessee Medical Center, Knoxville, TN, USA
Preston Dekker, DDS Department of Oral & Maxillofacial Surgery, University of
Illinois at Chicago, Chicago, IL, USA
Brett H. Diamond, MD Department of Radiation Oncology, Tufts University
School of Medicine, Boston, MA, USA
Sidney B. Eisig, DDS, FACS Oral and Maxillofacial Surgery, Columbia University
Irving Medical Center, New York, NY, USA
Edward Ellis III, DDS, MS, FACS Department of Oral and Maxillofacial Surgery,
UT Health San Antonio, San Antonio, TX, USA
Andrew R. Emery, DMD, MD Oral and Maxillofacial Surgery, Massachusetts
General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
M. Alejandro Fajardo, MD Department of General Surgery, School of Medicine,
University of Connecticut, Farmington, CT, USA

xi
xii Contributors

Justin Fazzolari, DMD Oral and Maxillofacial Surgery, Columbia University

Irving Medical Center, New York, NY, USA
Bridget Ferguson, DDS Oral and Maxillofacial Surgery, Columbia University
Irving Medical Center, New York, NY, USA
Elie M. Ferneini, DMD, MD, MHS, MBA, FACS, FACD Division of Oral and
Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
Beau Visage Med Spa and Greater Waterbury OMS, Cheshire, CT, USA
Department of Surgery, Frank H Netter MD School of Medicine, Quinnipiac
University, North Haven, CT, USA
Michael S. Forman, DMD, MD Division of Oral and Maxillofacial Surgery,
NewYork-Presbyterian/Columbia University Irving Medical Center, New York,
NY, USA
Joel M. Friedman, DDS, FACD, FICD, FPFA Division of Oral and Maxillofacial
Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center,
New York, NY, USA
Morton H. Goldberg, DMD, MD Division of Oral and Maxillofacial Surgery,
University of Connecticut, Farmington, CT, USA
Michael T. Goupil, DDS, MEd, MBA, FACD Division of Oral and Maxillofacial
Surgery, University of Connecticut, Farmington, CT, USA
Consultant in Oral and Maxillofacial Surgery, Carmel, IN, USA
Eric J. Granquist, DMD, MD Department of Oral and Maxillofacial Surgery,
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Steven Halepas, DMD, MD, FACD Division of Oral and Maxillofacial Surgery,
NewYork-Presbyterian/Columbia University Irving Medical Center, New York,
NY, USA
Gabriel M. Hayek, DMD, MD Division of Oral and Maxillofacial Surgery,
University of Connecticut, Farmington, CT, USA
Carlos R. Hernandez, DDS Department of Oral and Maxillofacial Surgery, UT
Health San Antonio, San Antonio, TX, USA
Kathryn E. Huber, MD, PhD Department of Radiation Oncology, Tufts University
School of Medicine, Boston, MA, USA
Christopher Hughes, MD, MPH Division of Plastic Surgery, Hartford Hospital
and Connecticut Children’s Medical Center/University of Connecticut, Hartford,
CT, USA
Leonard B. Kaban, DMD, MD, FACS Oral and Maxillofacial Surgery,
Massachusetts General Hospital, Harvard School of Dental Medicine, Boston,
MA, USA
Contributors xiii

Alia Koch, DDS, MD, FACS Division of Oral and Maxillofacial Surgery, NewYork-
Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
Kenneth Kufta, DMD, MD Department of Oral and Maxillofacial Surgery,
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Jessica S. Lee, DDS, MD, MA Private Practice, Northeast Facial & Oral Surgery
Specialists, Florham Park, NJ, USA
Kenneth MacCormac, DMD Division of Oral and Maxillofacial Surgery,
University of Connecticut, Farmington, CT, USA
John A. McNulty, PhD Loyola University Chicago, Stritch School of Medicine,
Maywood, IL, USA
Margaret A. McNulty, PhD Department of Anatomy, Cell Biology and Physiology,
Indiana University School of Medicine, Indianapolis, IN, USA
Christopher S. Midtling, DDS, MD Department of Oral & Maxillofacial Surgery,
University of North Carolina, Chapel Hill, NC, USA
University of North Carolina, Chapel Hill, NC, USA
Michael Miloro, DMD, MD, FACS Department of Oral & Maxillofacial Surgery,
University of Illinois at Chicago, Chicago, IL, USA
Keyur Naik, DDS, MD Department of Oral and Maxillofacial Surgery, New York
University Langone Medical Center/Bellevue Hospital Center, New York, NY, USA
Christine E. Niekrash, DMD, MDentSc Frank H Netter MD School of Medicine,
Quinnipiac University, North Haven, CT, USA
Benjamin Palla, DMD, MD Department of Oral & Maxillofacial Surgery,
University of Illinois at Chicago, Chicago, IL, USA
Daniel E. Perez, DDS, MS, FACS Department of Oral and Maxillofacial Surgery,
UT Health San Antonio, San Antonio, TX, USA
Michael Perrino, DDS, MD Riverside Oral Surgery, River Edge, NJ, USA
Peter D. Quinn, DMD, MD Department of Oral and Maxillofacial Surgery,
Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Utkarsh C. Shukla, MD Department of Radiation Oncology, Tufts University
School of Medicine, Boston, MA, USA
Dani Stanbouly, BS College of Dental Medicine, Columbia University, New York,
NY, USA
Mark H. Sueyoshi, MD Department of Radiation Oncology, Tufts University
School of Medicine, Boston, MA, USA
Pasquale G. Tolomeo, DDS, MD Tulsa Surgical Arts, Tulsa, OK, USA
xiv Contributors

Derek J. Tow, DMD, MD Division of Oral and Maxillofacial Surgery, University

of Connecticut, Farmington, CT, USA
Scott H. Troob, MD Department of Otolaryngology-Head & Neck Surgery,
NewYork-Presbyterian/Columbia University Irving Medical Center, New York,
NY, USA
Timothy A. Turvey, DDS, FACS Department of Oral & Maxillofacial Surgery,
University of North Carolina, Chapel Hill, NC, USA
University of North Carolina, Chapel Hill, NC, USA
Brian M. Will, DDS Division of Oral and Maxillofacial Surgery, NewYork-­
Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
Elizabeth M. Will, MD Department of Obstetrics & Gynecology, New York
University Langone Medical Center/Bellevue Hospital Center, New York, NY, USA
Michael J. Will, DDS, MD, FACS Will Surgical Arts, Urbana, MD, USA
Jason W. Yu, DMD, MD Section of Oral & Maxillofacial Surgery, UCLA School
of Dentistry, Los Angeles, CA, USA
 Part I
Early History
Saint Apollonia: Patron Saint of Dentistry

Christine E. Niekrash

1 Introduction

The exquisite pain of a toothache has afflicted humanity since ancient times. An
archaic Sumerian clay tablet written in approximately 5000 BCE describes dental
pain. Toothaches are mentioned frequently throughout literature worldwide. The
famous French barber-surgeon Ambroise Pare, writing in the 1500s CE, stated,
“Toothache is, of all others, the most atrocious pain that can torment a man, fol-
lowed by death.”
Dental pain appears in several of Shakespeare’s plays (Othello, Cymbeline, Much
Ado about Nothing). The famous Scottish poet Robert Burns wrote his “Address to
the Toothache” following his tormented bout with dental pain in 1786. For millen-
nia, people searched for relief from this debilitating pain, with many resorting to
crude methods of tooth extraction, pain relief, magic, and prayer.
For 1700 years, Christians around the world have implored Saint Apollonia
(Fig. 1) to extinguish their dental pain and to prevent it. For example, Cervantes
wrote in his epic work Don Quixote (published in 1615 CE): “‘Be in no pain then,’
replied the bachelor, ‘but go home, in Heaven’s name, and get something warm for
breakfast, and on your way repeat the prayer of Saint Apollonia – if you know it.’
‘Bless me!’ replied the housekeeper, ‘the prayer of Saint Apollonia, say you? That
might do something if my master’s distemper laid in his gums, but alas! It is all in

Some tortures are physical, And some are mental, But the one that is both is dental. — Ogden Nash

C. E. Niekrash (*)
Frank H Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 3

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_1
4 C. E. Niekrash

Fig. 1 Saint Apollonia.

Attributed to Piero della
Francesca c. 1455–1460.
(Courtesy National Gallery
of Art, Washington,
D.C. Reprinted without
alteration)

his brains.’” In 1557 CE, Francisco Martinez wrote the following prayer in his book
on dentistry published in Valladolid, Spain, one of many prayers to her:
“Illustrious virgin martyr, Apollonia,
Pray to the Lord for us
Lest our offenses and sins we be punished
By diseases of the teeth.”

Her life and legend are described below.

2  gypt 249 CE, the First Written Description

E
of Saint Apollonia

Alexandria is a port city on the Mediterranean Sea in northern Egypt, famous in the
past for its vast ancient library, its lighthouse, and the large pagan Temple of Serapis.
In the year 249 CE, it was a site of considerable turbulence and social unrest. The
city was controlled by the Roman Empire which was then in the middle of its
Imperial Crisis (235–284 CE), a period when various generals fought for control of
the empire. This era witnessed the rise and collapse of over 20 emperors and the
Saint Apollonia: Patron Saint of Dentistry 5

splintering of the huge empire. Widespread public discord resulted from the lack of
a clear policy for succession of the emperors which incited civil wars, inflation and
economic depression, the increased need for a larger army to provide protection of
the extensive empire against invading tribes, and the arrival of the plague.
In addition, burgeoning tensions and social strife arose between the increasing
number of Christians in the Roman Empire and those members of the polytheistic
pagan majority. In Alexandria in the mid-third-century CE, rioting and mob vio-
lence were common. From 244 to 249 CE, many Christians fled from Alexandria
during the rule of Roman Emperor Philip the Arabian (Marcus Julius Philippus
(reigned Feb 244–Sept 249)).
Celebrations were held in 248 CE to commemorate the millennium of the found-
ing of Rome (set at 753 BCE). During the festivities, a Roman poet is said to have
foreseen catastrophe caused by the Christians. As a result, a heathen mob inflicted
“bloody outrages on the Christians whom the authorities made no effort to protect”
(Kirsch 1907).
Saint Dionysius (then the Christian bishop of Alexandria), writing to Bishop
Fabius of Antioch, describes a specific incidence of pagan mob violence that tor-
tured several Christian individuals after the mob was incited by this poet. Saint
Dionysius wrote, “And the prophet and poet of evil to this city, whoever he was, was
beforehand in moving and exciting the heathen crowds against us, rekindling their
zeal for the national superstitions. So, they being aroused by him and availing them-
selves of all lawful authority for their unholy doings, conceived that the only piety,
the proper worship of their gods was this—to thirst for our blood.” In the letter, he
continues to describe the polytheistic mobs torturing several Christians. He contin-
ues, “Thereupon they all with one consent made a rush on the houses of the believ-
ers, and, falling each upon those whom they recognized as neighbours, plundered,
harried and despoiled them, setting aside the more valuable of their possessions and
casting out into the streets and burning the cheaper things and such as were made of
wood, till they produced the appearance of a city devastated by the enemy. But the
brethren gave way and submitted and accepted the plundering of their possessions
with joy…” (Feltoe 1918).
Saint Dionysius documents, “Another notable case was that of the aged virgin
Apollonia, whom they seized and knocked out all her teeth, striking her on the jaws:
then they made a pyre before the city and threatened to burn her alive, if she would
not join them in uttering blasphemies. But she asked for a brief respite, and being
let go, suddenly leapt into the fire and was devoured by the flames.” There are varia-
tions and embellishments of this story, some stating that she made the sign of the
cross when forced to worship the pagan idol, causing the statue of the Roman god
to explode. In fact, Apollonia most likely was an older Christian Deaconess from a
Greek family living in Alexandria. However, all versions of her life agree in report-
ing that her teeth were shattered and violently extracted to torture her before she
died because she would not renounce her faith. She is recognized as a Christian
martyr and was canonized about 50 years later, becoming Saint Apollonia.
6 C. E. Niekrash

3 The Legend

With the passage of time, St. Apollonia’s story became romanticized and embel-
lished. She evolved to become younger, more beautiful, and even more virtuous.
According to the developing legend, Apollonia’s father was a magistrate and her
parents were opulent, loving, and happy. Their only regret was their inability to
have children. Their frequent prayers to the pagan gods were unanswered.
However, three Christian pilgrims visited their home and presented the story and
teachings of Christ to the magistrate’s wife. The woman then prayed to the Virgin
Mary and Christ. Through this request, she subsequently gave birth to a daughter,
Apollonia.
Jacobus de Voragine wrote a chapter on Saint Apollonia in 1260 in his trea-
tise “The Golden Legend: Readings on the Saints,” one of the most widely read
medieval documents (de Voragine 1993). He describes her excruciating dental
torture and ultimate martyrdom in the fire. He concludes, “Oh, great and won-
drous struggle of this virgin, who by the grace of a compassionate God, went to
the fire so as not to be burned and was burned so as not to be consumed, as if
neither fire nor torture could touch her! There would have been safety in free-
dom, but no glory for one who avoided the fight.” He continues, “The merit of
this virgin, so gloriously and blessedly triumphant, excels and shines out among
martyrs.”
During the 1500s, the legend of Saint Apollonia was explained in the
“Rappresentazione di Santa Apollonia Vergine e Martire” (Eramo et al. 2017), a
stage production from Florence, Italy, that involved approximately 20 performing
actors and a still undiscovered musical score. This production corresponds with six
paintings of St. Apollonia by mannerist painter Francesco Granacci (Florence,
1469–1543) currently housed in the Accademia Gallery of Florence that illustrate
the key points of the Sacra Rappresentazione.
This religious drama, similar to the passion plays of Germany, further embel-
lishes the legend of Saint Apollonia. In this version, her father is King Tarsus. She
is raised as a pagan, but her interest in Christianity remains sparked by her mother’s
story of the role of the Virgin Mary in her birth. Apollonia is then converted to
Christianity by a hermit (Leonine, disciple of Saint Anthony) who baptizes her.
Ecstatic, she returns to Alexandria to preach and to convert the people, which angers
her father the king.
The production script describes that her father, furious with his daughter’s
response, sentences punishment for Apollonia by declaring,
“Take her and break her teeth
With pain as much as raw and strong
So that she experiences harsher torments
To make her error clear
And to set an example for rebels”
Saint Apollonia: Patron Saint of Dentistry 7

After she endures these tortures, Apollonia declares that even without teeth, she
can still speak well and continue to convert the people, and she refuses to worship
the idols. The emperor then orders her decapitation and a “cloud takes Saint
Apollonia’s soul and picks it up to Heaven.”

4 The Patroness of Dentistry and the Healer of Dental Pain

Christian patron saints are named to act as protectors or intermediaries between

humans and God and to intercede on the behalf of individuals who pray to them.
Often, the saint becomes the patron saint to protect against pain or affliction in the
particular part of the body that reflected their martyrdom. Because Apollonia had
been tortured by the destruction and extraction of her teeth, she became the patron
saint for those who suffered from toothaches and later by extension for those who
alleviate this pain, the profession of dentistry. In the Middle Ages, dental ailments
were prevalent and treated by a variety of procedures including bloodletting, leech-
ing, blistering of the skin, laxatives, cupping, placing garlic cloves in the ear, and
destroying the dental nerves by cautery using a red-hot iron or strong acid (Walsh
1897). The last resort solution was a brutal tooth extraction by barber-surgeons,
blacksmiths, or tooth-drawers at a monastery or a fair, all without anesthesia. On
certain days on the top of Capitoline Hill at the top of Araceli’s marble staircase in
Rome, Franciscan friars would extract teeth (Kelley 1919). Home remedies, elixirs,
amulets, or magic spells offered minimal or no relief (please see Chap. 3: Barber-­
Surgeons). During the medieval period, physicians first advised those experiencing
dental pain to pray to Saint Apollonia for divine intercession and relief. Journeyman
tooth-drawers typically wore pointed hats bearing the insignia of Saint Apollonia,
patron saint of toothache sufferers, and a necklace of extracted human teeth
(Wynbrandt 1998). In 1508 in Holland, Utrecht Brevier first mentions Saint
Apollonia as patroness of those who suffer from toothache. Churches and chapels,
statues, and paintings were created and dedicated in her honor.
Her feast day is celebrated on February 9 of each year by the Roman Catholic
Church, Alexandrian Church, Eastern Orthodox Church, and Coptic Church.

5 Relics

Within Christianity, relics are all or part of the mortal remains or objects associated
with a holy figure. (Harper and Hallam 1995). Christians have been venerating rel-
ics since the days of the Roman Catacombs (200–900 CE). Barbara Drake Boehm
explains the importance of relics in Christianity, writing “Relics were more than
mementos. The New Testament refers to the healing power of objects that were
8 C. E. Niekrash

touched by Christ or his apostles. The body of the saint provided a spiritual link
between life and death, between man and God: ‘Because of the grace remaining in
the martyr, they were an inestimable treasure for the holy congregation of the faith-
ful.’ Fueled by the Christian belief in the afterlife and resurrection, in the power of
the soul, and in the role of saints as advocates for humankind in heaven, the venera-
tion of relics in the Middle Ages came to rival the sacraments in the daily life of the
medieval church” (Boehm 2000).
In addition, and if possible, saints’ graves and churches housing relics were vis-
ited to attain divine intervention (pilgrimages). But the actual graves could be dif-
ficult to visit if they were located outside the city walls or far away. As a result, the
saint’s remains were exhumed and transported all over medieval Europe, usually in
pieces, and the relics were stored in churches and by royalty and the wealthy.
Christian relics reached their peak during the Middle Ages, but fraud often
occurred. King Philip II of Spain who reigned in Spain from 1556 to 1598, accord-
ing to Carlos Fuentes in The Buried Mirror (Fuentes 1992), “…surrounding himself
with such an avalanche of saintly relics. His agents searched far and wide to bring
him the skulls, shinbones, and withered hands of saints and martyrs, the relics of
Christ’s thorns and the True Cross, which he worshiped more than gold and silver.
In fact, Philip managed to amass all 290 holy teeth from the mouth of Saint
Apollonia, the patroness of toothache. The relic deposit at El Escorial must looked
like Citizen Kane’s warehouse at Xanadu.”
In 1543, church authorities ruled that every relic should have a special seal
(autentica), but the veracity of relics is difficult or impossible to ascertain. Reliquaries
(often very elaborate works of art) display and protect relics. They are often carried
in procession on the saint’s feast day and other holy days. This still occurs to com-
memorate Saint Apollonia in various locations around the world, such as the Church
of St. Brice in the Belgian city of Tournai.
Relics of Saint Apollonia were collected and displayed across Europe. According
to Kelley (Kelley 1919), her head was housed in the ancient Basilica of Santa Maria
in Trastevere in Rome, her arms in Basilica di San Lorenzo in Rome, and part of her
jaw in San Basilio also in Rome. Currently, in Rome, there is a Piazza Saint
Apollonia. Other Saint Apollonia relics have been attributed to a Jesuit church at
Antwerp, St. Augustine’s at Brussels, a Jesuit church at Mechlin (Belgium), St.
Cross at Liege (Belgium), and several churches in Cologne (Walsh 1897). Some of
these churches have closed or distributed their ancient relics, and records are diffi-
cult to verify.
An elaborate reliquary in the Cathedral in Porto, Portugal, displays a purported
tooth of Saint Apollonia (Fig. 2). Her alleged upper right first premolar with cervical
caries is displayed in the cathedral treasury of Rab (Croatia) (Skrobonja et al. 2009).
Saint Apollonia relics also exist in the United States. Examples include St.
Mary’s College in St. Marys, Kansas, the Shrine of All Saints at Saint Martha of
Bethany Church in Morton Grove, Illinois (personal correspondence with Father
Dennis), and the Church of St. Joan of Arc, Powell, Ohio (relics of St. Apollonia are
under the main altar with three other saint relics).
Saint Apollonia: Patron Saint of Dentistry 9

Fig. 2 Reliquary allegedly

contains tooth of Saint
Apollonia, Cathedral of
Porto, Portugal. (Wiki
Commons Image,
reproduced without
alteration)

6  t. Apollonia Commemorations: Statues, Churches, Plazas,

S
Paintings, Stained Glass Windows

Saint Apollonia is usually depicted as young and beautiful and with the same iden-
tifying symbols. She is most often holding forceps which frequently hold a tooth.
She is depicted with a crown (halo) or palm frond symbolizing martyrdom. Some
images include the pyre. Ancient art often displayed Saint Apollonia with a golden
tooth hanging from her necklace.
Germany houses many small chapels of Saint Apollonia (Aachen, Stein, etc.)
Lisbon, Portugal, named its train station Apollonia. England is home to more than
50 works commemorating her (Beal 1996), including chapels, stained glass, paint-
ings, and statues. Her image forms the side support of the coat of arms of the British
Dental Association. Belgium, Sweden, and the Netherlands also host many images
and commemorations of Saint Apollonia.
10 C. E. Niekrash

In the United States, Chicago houses a stained glass window depicting Saint
Apollonia in the Loyola University Madonna Della Strada Chapel (Fig. 3).
A statue of Saint Apollonia by Vincenzo Luccardi stands at the entrance of the
Leon Levy Library (Dental Medicine) in the University of Pennsylvania. She is
portrayed with a bandage around her jaw. The Boston Guild of Saint Apollonia,
founded in April 1920, performed charitable work among parochial school children
in the Boston area.
Paintings of Saint Apollonia appear in prominent museum collections such as the
Louvre, the National Gallery of Art, the Philadelphia Museum of Art, the Royal
Dental Institute of Stockholm, Sweden, and in a host of churches, chapels, and
smaller museums. Recently (1984), Andy Warhol created a series of silk screen
paintings of Saint Apollonia.

Fig. 3 Photographer:
Mark Beane, “Madonna
della Strada Chapel – St.
Apollonia of Alexandria
Window,” Loyola
University Chicago Digital
Special Collections,
accessed July 23, 2020,
http://www.lib.luc.edu/
specialcollections/items/
show/164. Reproduced
without alterations
Saint Apollonia: Patron Saint of Dentistry 11

Commemorations of Saint Apollonia are numerous, ancient and contemporary,

and in a variety of forms. To this day, in early February (to commemorate Saint
Apollonia’s February 9 feast day), special pancakes called Geutelingen are baked in
the Belgian town of Elst. It is believed that chewing this special pancake will offer
protection from toothaches.
Summary This chapter describes what is known about the life of Saint Apollonia,
a Christian martyr who was tortured by the violent extraction and destruction of her
teeth in 249 CE. She has been named the patron saint of those suffering from tooth-
ache and for those who alleviate that pain, the dental profession. This chapter
describes the evolution of her depictions and commemorations and the location of
various relics and works of art honoring her. Saint Apollonia is usually portrayed
holding a forceps displaying a tooth or wearing a necklace with a dangling golden
tooth. Her feast day is celebrated every February 9.

References

Beal JF. Representations of Saint Apollonia in British Churches. Dental Hist. 1996;30:3–19.
Boehm BD. Relics and Reliquaries in Medieval Christianity. In: Heilbrunn timeline of art history.
New York: The Metropolitan Museum of Art; 2000. http://www.metmuseum.org/toah/hd/relc/
hd_relc.htm (originally published October 2001, last revised April 2011).
de Voragine J. The golden legend: readings on the Saints (c.1260). Translated by Ryan,
W. Princeton: Princeton University Press; 1993.
Eramo S, Natali A, Bravi M, Cella D, Milia E. A “Sacra Rappresentazione” of Saint Apollonia’s
martyrdom. J Hist Dent. 2017;65(2):63–72.
Feltoe CL. (translator from the Greek) Saint Dionysius of Alexandria: letters and treatises
(36). London. The Macmillan Company; 1918. Translations of Christian Literature. Series
I. Greek Texts.
Fuentes C. The buried mirror: reflections on Spain and the New World. Boston: Houghton Mifflin
Company; 1992. p. 164.
Harper J, Hallam E. Secrets of the middle ages. New York: Kenecky and Kenecky; 1995.
Kelley H. Saint Apollonia-the patron saint of dentistry. J National Dent Assoc. 1919;6(5):400–12.
Kirsch J. St. Apollonia. The Catholic Encyclopedia. Vol. 1. New York: Robert Appleton Company;
1907. http://www.newadvent.org/cathen/01617c.htm.
Skrobonja A, Rotschild V, Culina T. Saint Apollonia’s Tooth – A Relic in the Cathedral Treasury of
Rab (Croatia). Br Dent J. 2009;207:499–50.
Walsh W. Curiosities of popular customs and of rites, ceremonies, observances and miscellaneous
antiquities. Philadelphia: Lippincott; 1897.
Wynbrandt J. The excruciating history of dentistry: toothsome tales and oral oddities from Babylon
to Braces. New York: St. Martin’s Griffin; 1998.
Anatomists: The Basis of Surgery

Margaret A. McNulty and John A. McNulty

1 Introduction

Surgery has been a part of dentistry and medicine since the beginning of civilization
with archeological evidence showing that as far back as 12,000 years ago, people
were subjected to drilling holes in the cranium (trepanation) supposedly to relieve
intracranial pressure or other neurological complaints (Gross 2012). Skeletal
remains in this same period had incisors with excavated pits (Oxilia et al. 2017),
while skeletal material dating to about 200 BCE included dental fillings comprising
a bronze wire inserted into the tooth canal (Yeomans 2019). Clearly, some knowl-
edge of anatomy was valuable to these early surgeons, but it was not until Claudius
Galen (129–199 CE) formally introduced anatomy and physiology in ancient
Greece as the disciplines comprising the foundation of dentistry and medicine.
This chapter highlights some of the historical hallmarks of anatomy, touching on
a few anatomical facts and anecdotes which are not typically covered elsewhere and
which we hope the reader will find interesting. For instance, it includes information
on the history of the sphenoid bone because it provides a specific example of how
anatomy has influenced dentistry and medicine over the years. Why the sphenoid
bone? Not only is it highly relevant to dentistry because it transmits important
nerves to the maxilla and mandible, but it has long mystified anatomists because of
its complexity and its obscure location at the base of the skull. Other sections of the
chapter review the evolution of modern anatomical imaging, as well as the history

M. A. McNulty (*)
Department of Anatomy, Cell Biology and Physiology, Indiana University School of
Medicine, Indianapolis, IN, USA
e-mail: [email protected]
J. A. McNulty
Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA

© The Author(s), under exclusive license to Springer Nature 13

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_2
14 M. A. McNulty and J. A. McNulty

of specimen acquisitions (cadavers) in anatomical education. Without the transmis-

sion of information, there can be no history. In reviewing the role of education, this
chapter shares some anecdotes from more than five decades of our combined expe-
riences as instructors of anatomy. The chapter closes with a brief history of art and
anatomy. Because of their common attention to form, it has been natural that art and
anatomy have been so closely aligned.

2 From Galen to Vesalius

Any recounting of the history of anatomy requires recognition of the many figures
who influenced the evolution of the discipline (Malomo et al. 2006; Mavrodi et al.
2013; Ghosh and Kumar 2019). Here, we draw brief attention to two of the most
notable contributors, Claudius Galen and Andreas Vesalius.
Claudius Galen of Pergamon (Fig. 1) was born into the Roman Empire in 129 CE
and, at the early age of 16, began his interests in medicine, which included extended
studies in Alexandria, Egypt, a well-known medical center at that time. His long
career included serving as physician to several emperors until his death at age 87.
Galen’s contributions to anatomy formed the foundation of medical knowledge
lasting almost 1400 years. He honed many of his skills as a physician and anatomist
through his treatment of gladiators wounded in the “games,” treating their wounds
as windows in the body, thus replacing dissections of human bodies, which were
illegal at the time. Because Galen was driven by the need to visualize anatomical

Fig. 1 Galen lithograph

by Pierre Roche Vigneron.
(Paris: Lith de Gregoire et
Deneux, ca. 1865)
Anatomists: The Basis of Surgery 15

structures through dissection, many of his observations were based on animal mod-
els, including Barbary apes. Among his most notable anatomical observations were
correct descriptions of seven of the 12 cranial nerves, the four valves of the heart,
the arterial/venous system, and functions of spinal nerves, especially the role of the
phrenic nerve in controlling contraction of the diaphragm (Malomo et al. 2006).
Galen was a prolific author completing several hundred publications, many of
which served as medical handbooks that formed the basis of medical education in
medieval universities once they were translated into Latin. These writings promoted
the discoveries of earlier physicians such as Hippocrates and Herophilus, but only
where they agreed with his observations. However, Galen’s works began to lose
favor when, by the mid-sixteenth century, the Flemish physician, Andreas Vesalius,
emphasized that Galen’s anatomical descriptions were principally from animals
rather than humans and contained numerous errors. Nevertheless, Galen still is
rightly recognized for his role in contributing to the rise of modern science and the
experimental method.
Galen’s publication (circa 180 CE) describing the skull bones is of particular
note because it was probably the earliest work known that included human material.
Most importantly to the subject of this chapter, he described the anatomy of the
sphenoid bone for the first time as “the bone which resembles a wedge (sphen hence
sphenoid) between the vault of the skull and the upper jaw” (Singer 1952). His
description goes on to include the sutures running along the temples meeting with
the coronal suture and descending to the palate to form a boundary with the upper
jaw. References to the winglike pterygoid plates were made.
As did Galen, Andreas Vesalius began his training in medicine and anatomy at
the early age of 18 in 1532 at the University of Paris, during which time he devel-
oped his skills in human dissection by venturing outside the walls of Paris to the
mound of Mounfacon where the decomposing bodies of executed criminals were
deposited (Mavrodi et al. 2013). He quickly rose in statue for his knowledge of
anatomy, giving lectures at the university using human material and culminating in
the publication of his book De humani corporis fabrica (On the Fabric of the Human
Body) in 1543 (Ghosh and Kumar 2019). As discussed below, this book revolution-
ized the medical world and replaced the Galenistic views of anatomy as the preemi-
nent reference because it provided more accurate descriptions of the human body.
Vesalius paid a high professional price and was roundly criticized for his corrections
of Galen’s writings (Malomo et al. 2006). He left the university, abandoned any
preparations of future studies, and lived out his remaining years as a physician until
his death in 1564.

3 The Sphenoid Bone

“Gentlemen, damn the sphenoid bone!” This quote attributed to Oliver Wendell
Holmes Sr. in his lecture to the Harvard medical class in the 1800s (Tubbs 2016)
emphasized dramatically the mystery and anatomical intricacies of this bone. It is
16 M. A. McNulty and J. A. McNulty

worth briefly noting that women were not admitted to medical school at that time,
though as Dean of Harvard Medical School, he worked to reform the admission
process to eventually include women (Tubbs et al. 2012).
The sphenoid bone contributes extensively to forming the base of the skull and in
this position articulates with a large number of other bones including the frontal,
parietal, ethmoid, zygomatic, temporal, occipital, palatine, and vomer bones and
through these articulations connects the neurocranium with the facial bones (Jamil
and Callahan 2020). Its complex anatomy is due in part to its embryological origin
from both mesodermal and neural crest derivatives. The principal components
include the body with the sella turcica housing the pituitary gland, the lesser wing
that transmits four cranial nerves to the orbit, the greater wings that contribute to the
calvarium, and the two pterygoid processes that serve as attachments for important
muscles of mastication. The greater wing contains the foramen rotundum transmit-
ting the maxillary nerve to the upper jaw and the foramen ovale for the mandibular
nerve innervating the lower jaw and tongue. The overall shape of the bone reminded
early anatomists of a bird or a bat with its body, wings, and legs (pterygoid processes).
The long history of the sphenoid bone was recently reviewed by Costea et al.
(Costea et al. 2018). Highlights of this review pointed out the contributions of
Vesalius (1555 CE), who referred to the bone as the cuneiform bone with “extraor-
dinary varied form” contributing to its designation as a “polymorphous” bone.
Vesalius presented all of the anatomy of the sphenoid bone up to that time (Fig. 2)
and corrected many of the errors in the anatomical descriptions of the bone,

Fig. 2 Drawings of the cranium and sphenoid bone, taken from Andreas Vesalius’ De corporis
humani fabrica, 1543
Anatomists: The Basis of Surgery 17

including those of Galen. Most importantly, Vesalius detailed all of the foramina
and structures (nerves, arteries, veins) passing through each foramen. This anatomi-
cal detail greatly expanded the importance of anatomy to medicine and surgery
because, as pointed out above, the cranial nerve innervation to the upper and lower
jaws pass through these foramina. More recent innovations have produced
360-degree interactive models allowing easier understanding of the complexity of
the bone and its foramina as well as surrounding structures (Jacquesson et al. 2017).
Medical issues specifically involving the sphenoid bone are not common, but in
1895, there was a remarkable account of severe caries in the sphenoid bone of a
physician (Day 1895). The disease progressed over a period of several months, and
its severity can be gleaned from the following description: “an area of diseased bone
2 cm. in length by 1 cm. in breadth could be seen and it was evident that the body
of the sphenoid and basilar process of the occipital bone were disintegrating.” On
postmortem examination, “The entire body of the sphenoid and basilar process of
the occipital bone were riddled with sinuses, exposing the external surface of the
dura and leaving it as the only protection and support of that part of the base of the
brain resting on the clivus blumenbachii. The pterygoid processes and ascending
rami of the palatine bones were carious and loose. The vomer was entirely gone, as
also the perpendicular plate of the ethmoid.” It was clearly a desperate situation.

4 Modern Anatomical Imaging

The foundation of dental surgery is based upon proper imaging of the anatomy, and
therefore, radiology plays an integral role in the history of dental surgery. Dental
imaging begins with the discovery of X-rays, a type of electromagnetic radiation
characterized by short wavelengths, by Wilhelm Conrad Röntgen, a professor of
physics at the University of Würzburg in Germany, in 1895. He discovered these
new rays, which he deemed “X-rays,” after noticing light near a glass vacuum
(Crookes) tube during one of his experiments. After his discovery of X-rays,
Röntgen was able to persuade his wife, Anna Bertha Röntgen, to place her hand on
a photographic plate, thus creating the first radiographic image of a human subject.
From there, it is unclear who made the first dental radiograph. Several individuals
in Germany, England, and the United States were using X-rays to take images of
teeth in early 1896, shortly after Röntgen’s discovery (Campbell 1995). However,
Friedrich Otto Walkhoff has been credited as taking the first dental radiograph, of
his own teeth, by holding an ordinary photographic glass plate during the 25-minute
exposure (Riaud 2014) (Fig. 3). Dr. C. Edmund Kells was likely the first dentist in
the United States to take intraoral X-rays in a living patient by developing a film
holder that would allow the patient to swallow during the process, which required at
least 15 minutes’ exposure time (Langland et al. 1972). In the early 1900s, dental
radiography increased in popularity, and German and American companies began
manufacturing dental X-ray machines.
18 M. A. McNulty and J. A. McNulty

Fig. 3 The first dental

X-ray image depicting the
teeth of Otto Walkhoff
(1896)

Unfortunately, these early X-rays were crude and not useful, and the dangers of
X-rays were soon realized by early radiology pioneers and those who volunteered
early on to serve as subjects. These subjects experienced radiodermatitis and ulti-
mately radiation-induced carcinomas following repeated exposure to the damaging
X-rays. Indeed, Dr. Kells himself suffered from extensive lesions on his hands that
refused to heal, ultimately resulting in 35 surgeries culminating in the amputation of
his entire left arm at the shoulder in 1926 (Langland et al. 1972). It was not long
before the correlation was made between the development of adverse health effects
secondary to X-ray exposure, though it was unclear to these individuals as to
whether the dangers came from exposure to the X-rays themselves or by the action
of the current passing outside of the tube (Kells 1899). However, further refinement
in the technique led to safer applications in the dental field. William Herbert Rollins,
a practicing dentist, was responsible for many techniques and devices that reduced
X-ray exposures. In 1896, he began to investigate the properties of X-rays, mostly
focused toward dental applications (Kathren and William 1964). In 1901, he pub-
lished a paper that correlated lesions on his hands to repeated and prolonged X-ray
exposure; he subsequently suggested other dentists and medical professionals
Anatomists: The Basis of Surgery 19

properly protect themselves, for example, by using glasses lined with lead and
enclosing the X-ray tube in a leaded box (Rollins 1901). However, his warnings
were not heeded until years later, and thusly, he ultimately became known as the
“Father of Radiation Protection.”
In the succeeding years, incorporation of radiological principles in the dental
field was assisted by several technical developments that made the technology safer
and more efficient for dental uses. In the mid-1920s, film replaced glass plates for
visualizing radiographic images. By 1925, the radiograph had become part of the
foundation of the practice of dentistry, and it was deemed necessary for diagnosing
and treating diseases and issues related to the teeth and jaws (Mooney 1925).
H. R. Raper introduced his new “bitewing” technique in 1926 and subsequently
published the details of his technique in a textbook (Raper 1926), which was widely
accepted at the time by those in the field as a large step in dental preventative medi-
cine (R H N. 1927), as it allowed visualization of the occlusal surfaces of the teeth.
Extraoral panoramic radiography was developed in 1949 by Yrjo V. Paatero, and
launched dental radiography forward, as it allowed for an unobstructed, two-­
dimensional image of the entire mouth (Hallikainen 1996). However, it was not
until the 1960s when commercial panoramic radiology units were manufactured in
Europe and the United States and were readily available to those practicing in
the field.
The technology that resulted in digital radiography known today was developed
beginning in the late 1970s with digital subtraction angiography (Korner et al.
2007). Numerous other technological advances have resulted in digital radiography
becoming increasingly available, even in remote hospitals and practices. These
advancements have made the process of obtaining oral radiographs far more effi-
cient and resulted in less radiation exposure for the patient and practitioner. Digital
radiography was first introduced into the dental field in 1987 by Dr. Francois
Mugnon with his RadioVisioGraphy system (Frommer and Stabulas-Savage 2011),
and the first digital dental panoramic unit was built by W. Doss McDavid at the
University of Texas Health Sciences Center in San Antonio. Shortly after, in 1995,
digital panoramic X-ray systems were available on the market.
More advanced radiological imaging techniques used to accurately assess ana-
tomical structures, such as computed tomography (CT) and magnetic resonance
imaging (MRI), have been increasingly integrated in dental practice. Originally
developed in 1967 by Sir Godfrey Hounsfield, CT scans were initially extremely
time-consuming, thus limiting their dental applications. Technological advances in
the imaging technique have significantly decreased scanning time and made the
imaging modality far more suitable for dentistry. Some applications include identi-
fying bony pathologies and assessing paranasal sinuses and the bony components of
the temporomandibular joint (Parks 2000). However, CT has not been widely uti-
lized in dental practice due to the high radiation dosage, cost associated with the
procedure, the lack of access to scanners, and experience required to adequately
interpret images, which is knowledge often not readily found in practicing dentists
(Kumar et al. 2015). Cone beam CT (CBCT), first introduced in the 1990s, allows
for accurate, 3D imaging of hard tissue structures using only a single rotation where
20 M. A. McNulty and J. A. McNulty

patient movement is not required and can negate the concerns associated with tradi-
tional CT in dental practice, resulting in improved diagnoses and patient safety
(Howerton and Mora 2007). The applications of CBCT in dental surgery include
identifying the exact anatomical location of pathologies such as tumors or bone
lesions, assessing impacted and supernumerary teeth, evaluating severity of osteo-
necrosis of the jaw, and evaluating paranasal sinuses (Fig. 4), among other applica-
tions, and are more widely utilized in oral surgery compared to traditional CT
imaging.
In the history of radiological imaging, MRI is a relative latecomer to the field.
While the research in physics that led to the development of MRI dates back to
1938, it was not until the 1970s that it was demonstrated to be possible to use
nuclear MR to create an image (Lauterbur 1973). Compared to the other radiologi-
cal imaging modalities that utilize ionizing radiation, MRI has a promising future in
dentistry. The ability of the technique to distinguish between various soft tissues
makes it an ideal imaging technique to diagnose temporomandibular joint dysfunc-
tion (TMD) and dental implant planning (Niraj et al. 2016). MRI techniques are also
being used for a variety of other conditions that benefit from identifying the exact
anatomical location and extent of disease, including early bone changes secondary
to tumor formation and fractures (Niraj et al. 2016).

a b

c d

Fig. 4 Three-dimensional reconstruction of the sphenoid sinus using CBCT. (a) axial view,
(b) sagittal view, (c) coronal view, (d) final volumetric reconstruction (Nejaim et al. 2019)
Anatomists: The Basis of Surgery 21

5 A Brief History of Cadaver Acquisition for Education

The study of anatomy is an active science involving dissection of the human body
to discover its parts, hence a need for human material, which provided a tumultuous
history of its own affected by cultural mores, religious constraints, and supersti-
tions. Leonardo da Vinci in the late fifteenth century was among the first to incorpo-
rate dissections to accomplish his detailed renditions of the human body. His
dissections of human corpses were mostly from hospitals in Florence, Milan, and
Rome, and they led to a better understanding of the physiology and the mechanics
of joint movements. Vesalius followed shortly thereafter, and in contrast to da Vinci,
who had many eclectic interests, he was much more focused on the surgical and
anatomical specialties. Vesalius was a strong proponent of dissection as a teaching
tool and relied for the most part on executed criminals for his studies. One such dis-
section of a felon (Jacob Karrer) from Switzerland prepared by Vesalius in 1543
resulted in a well-preserved and the oldest surviving skeletal preparation displayed
in the Anatomisches Museum at the University of Basel.
This reliance on executed criminals for anatomical studies has persisted since the
sixteenth century. Siegfried Zitzelsperger, an anatomist who trained in Germany in
the early 1930s, recounted as a young student waiting for completion of an execu-
tion before he and his colleagues rushed in to quickly remove the spleen from the
deceased to perfuse it with latex to make a case of the circulatory system (personal
comm.). More recently, the Visible Human Project (VHP) (2019) compiled a large
data set of cryosectioned, cross-sectional images from a male and a female. The
male donor was Joseph Paul Jernigan, a 38-year-old Texas murderer who was exe-
cuted by lethal injection. The VHP was funded by the National Institutes of Health
Library of Medicine to increase the availability of high-resolution electronic images
correlated with both MRI and CT images. The anatomical axial images were col-
lected from the removal of cryosections at 4 mm intervals for the male and 0.33 mm
intervals for the female. The completed data sets have been widely licensed for use
in noncommercial and commercial applications for education and research.
The use of executed criminals for dissection was legitimized in the Murder Act
of 1751 by the Parliament of Great Britain (Mitchell et al. 2011). It was intended to
prevent acts of murder if potential offenders knew that they would be dissected fol-
lowing execution. The act also provided a supply of bodies to the Royal College of
Surgeons for this purpose. While executions of convicts provided a source of cadav-
ers for study, it was not terribly reliable and did not provide sufficient numbers of
cadavers as dental and medical education programs grew in number. In order to
make up this supply gap, rather gruesome activities sprang up including murder of
the homeless and grave robbing. One notorious episode occurred in Scotland in the
early 1800s where two Irishmen murdered 16 unsuspecting people under different
conditions and sold their bodies to a member of the Royal College of Surgeons of
Edinburgh who taught anatomy and advertised demonstrations using fresh anatomi-
cal subjects for each lecture. The crime of murder for the purpose of selling bodies
for dissection became known as “burking,” named after one of the offenders,
22 M. A. McNulty and J. A. McNulty

William Burke (Harris 1920). A direct consequence of this “burking” incident was
the passage of the British Anatomy Act of 1832, which rescinded the Murder Act
and enhanced the availability of human bodies from physicians legally responsible
for patients who had died in hospitals and other facilities and who had not been
claimed by relatives in over 48 hours.
If murder or legal acquisition of human bodies was not an option, then stealing
bodies which had already been buried became an alternative. Over time, an impor-
tant distinction has arisen between “grave robbers” and “body snatchers.” The for-
mer includes those who rob burial sites for profit (including archeological sites).
The latter are those individuals interested only in the deceased, usually for sale to
medical schools or other professionals to dissect. One example occurred in the
1850s in Illinois. According to the account published in the Joliet Herald News
(1997), three physicians in the area required a body to dissect to resolve some unan-
swered anatomical questions. A young medical student (Keeny), the brother-in-law
of one of the physicians, volunteered to recover the body of an elderly woman
recently interred. Keeny delivered, the physicians dissected, but Keeny lost his
nerve when returning the body to the grave and left it in a quarry covered with
stones and snow not to be discovered until the spring thaw. The newspaper account
included courtroom dramas involving false accusations and a local play recounting
the affair, but the story ended without resolving the fate of Keeny and the three
physicians.
Today, cadavers for anatomical teaching and research are obtained legally
through donor programs that rely on the altruism of the general public to donate
their remains upon their death. In most cases, individual medical schools have their
own programs to support their needs. In other cases, several universities consolidate
resources such as the Anatomical Gifts Association in Illinois, which collects and
distributes donors to seven medical schools in the greater Chicago area. Government
regulations strictly control the distribution and use of any human remains.

6 Anatomy Through Art and Atlases

The human body as the subject of art is a constant from the earliest cave drawings
with the prevailing link between art and anatomy (other than the human form) being
reliance on the visual sense. As the artist lends perspective through a painting, the
anatomist reveals relations of structures through dissection. This anthropocentric
nature of art and anatomy is highlighted by the dependence of anatomical study on
artists’ abilities to capture and render complicated anatomical elements in a three-­
dimensional perspective. Examples of these artistic accomplishments are abundant
(Mavrodi et al. 2013).
In 1490 AD, Leonardo da Vinci (1452–1519), an accepted genius for his contri-
butions in mathematics, chemistry, mechanics, and art, sketched a drawing of the
proportions of the human body he made from measurements of models in Milan,
Italy. The drawing represents accurate proportions of the human body within a
Anatomists: The Basis of Surgery 23

square and a circle. It is referred to as “Vitruvian Man” (Fig. 5) because it was based
on descriptions of the Roman architect Vitruvius. It combines mathematics (propor-
tions) and art as only Leonard da Vinci could do, which qualified it as an important
message we have sent into space many times on formal embroidered patches worn
by NASA astronauts. One design includes an astronaut in a space-walk suit in the
same position depicted in the “Vitruvian Man” and is worn on the right shoulder of
US space suits engaged in extravehicular activity space walks. The “Vitruvian Man”
was also featured on patches worn by NASA’s Expedition 37 crew that traveled to
the International Space Station in 2013.
One of the more famous paintings combining art and anatomy was “The Anatomy
Lesson of Dr. Nicolaes Tulp” by Rembrandt (1632) (Fig. 6). The painting depicts
Dr. Nicolaes Tulp, who was Doctor of Medicine and Praelector Anatomiae to the
Amsterdam Guild of Surgeons, demonstrating a dissection of the forearm to other
members of the guild. Such demonstrations were common in medical centers across
Europe, and though they originally were for educational purposes, they evolved to

Fig. 5 Vitruvian Man by

Leonardo da Vinci
24 M. A. McNulty and J. A. McNulty

Fig. 6 “The Anatomy Lesson of Dr. Nicolaes Tulp” by Rembrandt (1632)

become more public events where local residents would pay an entry fee to the
anatomy theater where they viewed skeletal material when there was no cadaver
dissection.
Over the years, anatomists have questioned whether Rembrandt erred in his
depiction of the muscles shown dissected in the left forearm, specifically whether
the extensor or the flexor muscles are represented. The suggestion of an error was
based primarily on anatomic atlas drawings, especially on the origin of the muscles
that Dr. Tulp is holding in his forceps. These muscles appear to originate from the
lateral epicondyle of the humerus. However, if he painted the flexor (anterior) aspect
of the forearm as suggested by the position of the thumb, those flexor muscles origi-
nate from the other side of the humerus, the medial epicondyle. One compelling
argument that the dissection represents the flexor forearm muscles is the clarity with
which the tendons of the superficial flexors of the digits divide to allow passage of
the tendons of the deep flexors are painted on the distal digits. In order to address
this question of whether or not the painting was in error, Ijpma et al. undertook a
detailed dissection of a male cadaver’s flexor forearm photographed at different
stages of the dissection (FF et al. 2006). They reported that Rembrandt’s depiction
of Dr. Tulp’s dissection could be reasonably reproduced by selectively cutting and
displacing specific forearm muscles supporting the notion that Rembrandt did not
err in his painting. Though it must be pointed out that even if he had erred, it would
not have distracted from the historical blending of art and anatomy.
Anatomists: The Basis of Surgery 25

The relationship between art and anatomy transformed into drawings to help
supplement the dissection and especially in those cases where dissection was not
possible to substitute with detail as lifelike as possible. The period of the fifteenth to
the seventeenth century was a time of rapid development of visual aids important to
the furtherance of the anatomical sciences. Leonard da Vinci (1452–1519) set the
stage with his drawings of the skeletal system (Fig. 7), muscular system, the heart
and vascular system, and sex organs along with other internal organs.
Soon after, Andreas Vesalius (1514–1564) compiled what can be considered the
first comprehensive atlas of anatomy, De Humani Corporis Fabrica (“On the Fabric
of the Human Body”). The Fabrica comprised a series of books on the skeletal sys-
tem, muscular system, nervous system, vascular system, brain, and heart and was
most likely the large book depicted in Rembrandt’s painting, “The Anatomy Lesson
of Dr. Nicolas Tulp.” The following 300 years saw further refinements in the ana-
tomical publications combining text and drawings including authors very familiar to
anatomists such as Morgagni and Charles Bell (Bell’s palsy).
What can be considered a second milestone in the evolution of atlases and text-
books in anatomy was the work of Henry Gray (1827–1861) who published in 1858
the legendary book “Anatomy, Descriptive and Surgical” otherwise known as
“Gray’s Anatomy.” This book has become the central authority of human anatomy
and is a common fixture on anatomists’ bookshelves. As a member of the Royal
College of Surgeons and as the book’s title implied, Henry Gray had as his main

Fig. 7 “The skull” by

Leonardo Da Vinci, 1489
26 M. A. McNulty and J. A. McNulty

objective to improve the skills of surgeons through the application of detailed ana-
tomical knowledge. The book was the culmination of years of personal, methodical
dissections, and its success was greatly enhanced by the illustrations made by Henry
Carter, a demonstrator working with Gray. Carter’s illustrations were direct and
nomenclature added for ease of reference with the text, a style that has persisted to
the present. It was another century before the next milestone in anatomical atlases
arrived with the publication of Frank Netter’s “Atlas of Human Anatomy” in 1989.
Netter’s training as a physician and an illustrator combined to produce color illus-
trations that were rich in detail and lifelike rendition. His atlas is a staple of medical
education and, along with “Gray’s Anatomy,” has found a place on most book-
shelves of anatomists and surgeons.
As the Internet and computer technology expanded in the twenty-first century, it
allowed individual anatomists to become publishers and to produce their own ana-
tomical “atlas” and either publish to the wider audience or keep them solely for in-­
house use within their own courses. Paramount to this process was the ease with
which dissections could be photographed and distributed to fulfill any need essen-
tially on the fly. The extension of multimedia to include videos allowed dynamic,
dimensional anatomical presentations that static illustrations can never duplicate.
Combined with the technological advancements in radiological imaging, including
the ease of obtaining CT and MRI scans of living individuals, it has never been
easier to obtain high-resolution images of anatomical structures. Combine the ease
of obtaining images with the ease for anyone to create a website, and the result is a
large variety of Internet-based resources created by anatomists and institutions
around the world. These technological and specifically imaging advancements are
of particular use to surgeons who rely on detailed knowledge of head and neck
anatomy, which has been previously difficult to comprehend due to its complexity.
It is now possible to create detailed digital anatomical resources that can incorporate
soft tissue and osseous structures into three-dimensional images that can be manip-
ulated by the learner, such as the structures surrounding and passing through the
complex sphenoid bone (Nowinski and Thaung 2018) (Fig. 8). There are many

Fig. 8 A 3D
reconstruction of MRI and
high-resolution CT scans
of the sphenoid bone with
surrounding
neurovasculature, taken
from a normal male
(Nowinski and Thaung
2018)
Anatomists: The Basis of Surgery 27

digital resources that are also freely available to the general public, creating an
opportunity for the anatomy of the human body to be freely explored by those both
within the medical fields and the general public. These resources are not limited to
only digital; 3D printing of anatomical structures, including pathologies from actual
patients, allows clinicians to perform simulated surgeries on these printed structures
to determine the best course of surgical action, which has not been previously pos-
sible preoperatively (Lin et al. 2018).
With the continued development of artificial intelligence algorithms and virtual
reality, it is easy to imagine how future anatomists and surgeons will experience
anatomical and surgical education in the comfort of their chair. And indeed, this has
already become a reality for most students and instructors of anatomy as a direct
result of the COVID-19 pandemic. Research conducted prior to the shift to entirely
virtual instruction indicated that learning supplemented with these novel digital
resources improved short-term learning of anatomy compared those who only
learned via dissection-based methods (Wilson et al. 2019). While research is still
ongoing as to the ultimate impacts of COVID-19 online anatomy instruction for
professional medical and dental students, it is increasingly apparent that these novel
digital technologies are primarily useful as a supplement to anatomy instruction and
will not be able to replace in-person dissection of human cadavers (Singal et al.
2020; Iwanaga et al. 2021).

7 Summary

The knowledge of anatomy is the building block that all surgical principles rely on.
Our species understanding of anatomy and physiology is the foundation of medi-
cine. With the advancement of medical imaging and computer technology, the
future of studying human anatomy will continue to evolve dramatically.

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The Barber-Surgeons

Michael T. Goupil

1 Introduction

The barber-surgeons were the primary surgical healthcare providers from the elev-
enth to the seventeenth centuries in Europe. As barbers, they were experienced in
the use of sharp instruments and thus well adapted to fill the void that physicians
were unable to perform. Their procedures ranged from cutting hair to bloodletting,
tooth removal, and setting bones (Fig. 1).

2 Origins

Barber-surgeons came into existence around 1000 CE. They were considered the
medical and grooming experts of Europe (Hue 2017). The separation of surgery
from traditional medicine dates back to the early Hippocratic Oaths that cautioned
physicians from practicing surgery due to their lack of knowledge (Thamer 2015).
The origin of barber-surgeons is attributed to a number of edicts proclaimed by
the popes in the twelfth century. One of the functions of the religious prior to these
edicts was to provide for both the spiritual and physical health of their followers.
Pope Innocent II issued edicts against the study and practice of medicine through
the Council of Clermont (1130), Council of Rheims (1131), and Lateran Council
(1139). The interpretation of the edicts in general prevented monks from conducting
procedures that led to bleeding. This prohibition was reinforced with the edicts of
Pope Alexander III through the Councils of Montpellier (1162) and Tours (1163).

M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
Consultant in Oral and Maxillofacial Surgery, Carmel, IN, USA

© The Author(s), under exclusive license to Springer Nature 31

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_3
32 M. T. Goupil

Fig. 1 “The Surgeon” by David Teniers the Younger, 1670s. (Reproduced without alteration, pub-
lic domain image)

Initially, the edicts prohibited higher clergy from the study and teaching of medicine,
but the later edicts extended to lower monks and eventually forbade all bleeding and
cutting (Amundsen 1978).
Barbers were already part of monastic societies as monks had specific grooming
needs for their required tonsures. As barbers were well versed in the use of razors
and scissors, it was only natural for the monks to teach the barbers the surgical tech-
niques they were no longer permitted to perform (Amundsen 1978; Hue 2017).
The Black Plague in the fourteenth and fifteenth centuries led to the demise of
many of the university-trained physicians. This led to an ever-increasing need for
barber-surgeons and their expanded surgical role.

3 Scope of Practice

Two of the most common procedures performed by barber-surgeons were the draw-
ing of teeth (see Chap. 9, Evolution of Tooth Removal) and bloodletting which was
based on Greek and Roman medical practice (Fig. 2). One of the continued beliefs
in the Middle Ages, for the cause of disease, was an imbalance of the four
The Barber-Surgeons 33

Fig. 2 The ancient art of

bloodletting. Reproduced
without alteration, public
domain image

humors – sanguine, choleric, melancholic, and phlegmatic. A common practice in

diagnosing an hormonal imbalance was to examine the urine for color, consistency,
and taste (The Gory History of Barber Surgeons 2019). Once the diagnosis was
made, the patient underwent bloodletting, by cutting one of the veins, to reestablish
a balance in the humors.
War was a popular pastime in the Middle Ages, and this led to an expansion of
the barber-surgeons scope of practice. The craft of barber-surgeons was limited to
basic trauma, stabilization of broken bones, sword and knife wounds, and now the
new injuries associated with gunpowder (Schneider 2020). Broken bones were set,
limbs were amputated, and bleeding was stopped. The one benefit of armed conflict
is the development and expansion of surgical procedures. As monasteries took on a
larger role as hospitals, barber-surgeons provided bone setting and limb amputation
in the surrounding community.

4 European Medical Education

The first secular European medical school was established in Italy at Salerno.
Subsequently, medical schools were established at Montpelier, Bologna, Paris,
Oxford, and Cambridge (Bagwell 2005). Surgery was considered part of the medi-
cal education system in Italy, and thus, barber-surgeons did not play a prominent
role there as opposed to France and England.
In France, medical education was provided on three levels. Physicians were at
the top of the healthcare pyramid. They received their education at universities and
34 M. T. Goupil

were licensed by the university. In the thirteenth century, physicians were required
to take an oath not to perform surgery. Second in hierarchy were the surgeons of the
long robe. They studied medicine for two years and surgery for two years before
entering the surgeon’s guild as Master Surgeons. The hallmark of the physicians’
and surgeons’ education was their instruction was conducted in Latin and Greek. At
the hierarchy bottom were the barber-surgeons or the surgeons of the short robe.
Lacking the ability to read, write, or speak Latin or Greek, they had no formal medi-
cal education. The barber-surgeons learned their craft through an apprenticeship
usually lasting at least 5 years before they were eligible to be examined and obtain
the designation of Master Barber-Surgeon (Garant 2013).
The Guild of Barbers was formed in Paris in 1210. The distinction between the
long robe and the short robe was based on education (Ring 1985). The long robe
indicates a university education, whereas the short robe designates an apprentice-
ship supervised by a guild. By royal decree in the fourteenth century, surgeons of
the short robe were prohibited from performing surgery until passing an examina-
tion given by the surgeons of the long robe (Wynbrandt 1998).

5 Notable Barber-Surgeons

Ambroise Paré (see Chap. 4, The Three Pillars of Surgery) became the greatest
surgeon of the sixteenth century, and because of his advances in surgery gained
through his military experiences and extensive writings, he is often called the Father
of Modern Surgery (Fig. 3).
He was born in 1510 in northwest France. Paré’s father, elder brother, and
brother-in-law were all barber-surgeons. He moved to Paris for his apprenticeship
and eventually became a wound dresser at the Hôtel-Dieu de Paris, the oldest hos-
pital in Paris. He eventually passed his examination for the rank of Master Barber-­
Surgeon in 1536.
He spent the next 30 years in the military where he developed new techniques for
the treatment of gunshot wounds. He drew significant criticism from physicians and
surgeons of the long robe as his writings were in the French vernacular as opposed
to the traditional Latin of the medical profession.
Because of his reputation as a compassionate and innovative practitioner, he
became the barber-surgeon to four French Kings – Henri II, Francois II, Charles IX,
and Henri III. Paré also had an extensive dental practice, stabilizing jaw fractures
with gold wire and replanting avulsed teeth (Garant 2013; Ring 1985; Swartz 2015).
Richard le Barbour became the first Master of the Barbers in London in 1308. He
was responsible for the supervision of all barbers in the city of London. Based on
monthly inspections, he was to ensure that barbers were not “keeping brothels or
acting in an unseemly way” (Sprague 2008).
The Barber-Surgeons 35

Fig. 3 Portrait of
Ambroise Paré
(1510–1590) by William
Holl. Reproduced without
alteration, public domain
image

Barber-surgeons were the first healthcare professionals to focus on providing

medical care to soldiers in both war and peace time. Hinsikinus was the first barber-­
surgeon referenced in Finland. He was hired to prepare medicine and care for the
wounded from 1324 to 1326. Finland gained its independence in 1917 and no longer
felt that there was a need to provide barber-surgeons for the military (Kuronen and
Heikkinen 2019).
Jan van Riebeeck (1618–1677) was inducted into the Guild of Barber-Surgeons
in Amsterdam in 1634 where he served a 4-year apprenticeship. He was the first
founder of the Colony of Good Hope which is now known at the Republic of South
Africa (Bird 1965).

6 The London Barber-Surgeons’ Guild

Guilds and companies were originally established for social and religious interac-
tion. The trade guilds were responsible for apprenticeships and the regulation of
their specific trades.
36 M. T. Goupil

Fig. 4 Henry VIII and the Barber-Surgeons, by Hans Holbein the Younger; The Worshipful
Company of Barbers

The Worshipful Company of Barbers has been in existence for over 700 years.
This first reference to this guild was in the early twelfth century and probably was
founded earlier than that. As noted above, Richard le Barbour was the first Master
Barber. The first surgeon was admitted to the company in 1312.
A surgeons’ guild was established in London in 1435, and they claimed the right
to regulate the practice of surgery, thus competing with the barbers. In 1462, King
Edward IV granted the barbers its first royal charter to regulate practice of surgery.
This act was commemorated in a painting by Holbein (Fig. 4).
In 1540, an Act of Parliament established the Company of Barbers and Surgeons
of London and established their respective roles. Surgeons could no longer cut hair,
and barbers could no longer perform surgery, but both groups could continue to
draw teeth.
In 1745, the surgeons left the company and formed the Royal College of Surgeons
of England. In 1919, the relationship between the surgeons and barbers was reestab-
lished, and surgeons are now regularly admitted to the company. The company has
returned to the original intent of the guild system for social and charitable activities
(Dobson 1974; The Worshipful Company of Surgeons (Dobson and Walker 1979).

7 Barber Pole

Because the majority of people were unable to read, businesses and professionals
used signage to indicate the services that they provided. The well-known red and
white barber pole indicated the services of the barber-surgeon. The red on the pole
The Barber-Surgeons 37

Fig. 5 Modern-day
barber pole

represented the blood from the primary service of bloodletting, and the white on the
pole symbolized bandages. The blue stripe represents the “blue pole” that was dis-
played outside of the offices of surgeons (Wynbrandt 1998). Even though barbers no
longer provide surgical services, many barber shops have retained this universal
symbol (Fig. 5).

8 End of an Era

The need for formal medical education as part of a surgeon’s training had been rec-
ognized. In 1743, Louis XV, the King of France, prohibited any barber or wig maker
from performing surgery (The Gory History of Barber Surgeons 2019), while in
38 M. T. Goupil

London in 1745, the surgeons separated from the barbers to form their own profes-
sional society. The extraction of teeth could still be accomplished by either surgeons
or barbers.

9 Summary

Barber-surgeons provided a significant role in the delivery of healthcare during the

Middle Ages and the Renaissance. The innovations and writings of barber-surgeons
like Ambroise Paré during this period helped develop and shape the field of surgery
as known it today.

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Thamer S. Bloody history of barber surgeons https:/Mdrynyu.Org/
Fall-2015-Bloody-History-Of-Surgeons/.
The Gory History of Barber Surgeons: Medieval Medicine Gone Mad. Ancient origins: recon-
structing the story of humanity’s past. Ancientorigins.net. 2019.
The Worshipful Company of Surgeons. Barberscompany.org.
Wynbrandt J. The excruciating history of dentistry. New York: St Martin’s Press; 1998.
The Three Pillars of Surgery

Morton H. Goldberg

1 Introduction

The triad of hemostasis, anesthesia, and asepsis is the three pillared foundation of
the contemporary glory and wonder that is twenty-first-century surgery and all of its
specialties and subspecialties. Without prevention and control of bleeding, pain
management, and infection control, one would never have progressed from the not-­
so-­distant era of screaming, restrained patients undergoing burning cautery control
of hemorrhage, or facing death from deep or generalized infections. More simply
put, a three-legged stool has little value if one or more of its struts is absent or
inadequate.
The solution and management of these fundamental surgical problems can be
attributed to many physicians and surgeons throughout history. But because of their
keen observation skills, appreciation of medical history, common sense, and cour-
age to go against the established norms, even in the face of intense criticism, three
names rise to the surface – Paré, Wells, and Lister.

2 Hemostasis – Ambroise Paré

Ambrose Paré (1510–1590) was born in Bourg-Hersnet near Laval, France (Fig. 1).
Little is known of his early life. His father has been described as a cabinet maker,
but tradition describes him as the valet de chambre and barber to the Sieur de Voul
(Hernigou 2013a). Paré’s older brother and his brother-in-law were both barber-­
surgeons, and thus, it is not surprising that Paré followed in the family tradition and
was apprenticed as a barber-surgeon (Ellis and Abdella 2019a). Because of his

M. H. Goldberg (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA

© The Author(s), under exclusive license to Springer Nature 39

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_4
40 M. H. Goldberg

Fig. 1 Portrait of
Ambroise Paré, 1582.
Reproduced without
alteration, public domain
image

interest in surgery, Paré, at the age of 22, went to the Hôtel Dieu (Sherzoi 1999)
which was the oldest hospital in Paris where he continued to study as a barber-­
surgeon treating the sick and poor. Fortunately for Paré, the Hôtel Dieu had recently
become associated with the University of Paris, and as a barber-surgeon, he was
able to attend lectures in anatomy and surgery at the medical school (Bracker 2008;
Markatos et al. 2018). Additionally, he was able to receive hands-on experience
from the attending surgeons.
Because of a lack of finances, Paré was unable to pay for his examination as a
master barber-surgeon at the end of his apprenticeship. Instead, at the age of 26, he
started his career as a military surgeon (Ellis and Abdella 2019a). He served his first
of 17 military campaigns (Goyal and Williams 2010) at the Siege of Turin
(1536–1537) where he made his first major contribution to military surgery. The
traditional method of treating battlefield wounds was boiling oil. Paré was a com-
passionate practitioner, and the pain induced by this treatment caused him a great
deal of stress. Because of the inflicted pain and now a shortage of oil, Paré sought
an alternate treatment method. He formulated a salve composed of egg yolk, oil of
rose, and turpentine, a method that had been used by the Romans a thousand years
earlier (Bishop 1995a; Ring 1985a). The next morning, he noted that the wounds
treated by boiling oil were showing signs of infection as opposed to those treated
The Three Pillars of Surgery 41

with his salve. Paré published this technique in 1545 The Method of Treating Wounds
by Arquebus and Other Firearms. Not only had Paré broken with the traditional
Galenic medical practice, but he also published his work in the French vernacular as
opposed to the accepted medical writing if Latin (Bracker 2008; Ring 1985b.).
Wounds on those numerous battlefields were created by early forms of the
matchlock musket (arquebus) as well as by arrows, lances, and swords. Those who
suffered deep wounds of the abdomen, chest, or cranium were left to their inevitable
fate, but combatants with limb or facial wounds might survive if the initial hemor-
rhage could be controlled. The traditional method of wound hemostasis had been,
for centuries, burning by red-hot iron cautery or by pouring boiling oil into the
wound. Some of the battlefield barber-surgeons of that era boiled puppies in the oil,
convinced that this contributed to controlling blood loss.
Paré, the Father of Modern Surgery, had learned the use of cautery at the Hôtel
Dieu in Paris, but he recognized that the burned tissue frequently became infected,
necessitating amputation which led to further blood loss and the need for more cau-
terization. Amputation was one of the most common surgical procedures performed
in the sixteenth century (Baskett 2004). His contemporaries, however, believed that
many wound infections were the result of “gunpowder poisoning.” The technique of
suturing for lacerations or cutaneous surgery had been utilized for centuries in
China and the Arab world. Paré reasoned that suturing could be applied to large
deep wounds in lieu of cautery or hot oil and puppies. Hence, his innovative and
often lifesaving development of the suture ligature. In order to clamp a bleeding
vessel prior to tying in with a ligature, he modified the “bec de corbin” (crow’s
beak) which is considered to be the precursor of the modern hemostat (Hollingsham
2008a). Though suturing of wounds had been advocated by Hippocrates, Galen,
Celsus, and Avicenna, Paré was the first to put his technique to a practical use when
performing an amputation (Markatos et al. 2018; Hernigou 2013b). His first attempt
was at the Siege of Danville in 1552 (Ellis and Abdella 2019a; Shah 1992), later
publishing the technique in his classic Treatise on Surgery (Dix livres de la chirur-
gie) in 1564 (Fig. 2).
While also developing innovative dressings and sliding skin flaps to close defects
created by injury or excision, Paré’s fame spread, ultimately resulting in him becom-
ing court surgeon to the infamous French queen, Catherine de Medici, having served
as court surgeon to five French kings. His discoveries and procedures were accom-
plished despite centuries old entrenched surgical dogma, but he prevailed. He had
erected the first of the three pillars of successful modern surgery, hemostasis.
Perhaps William Halsted, the “father of American Surgery,” had Paré in mind
when, 300 years later, he taught his oft-repeated maxim “treat tissue gently and it
will reward you by healing quickly.” One of Halsted’s fellow surgeons at John
Hopkins built further on Parés’ concepts and perfected hemostatic clamps: thank
you, Dr. Howard Kelly!
Today, every day, surgeons clamp, ligate, and suture in ORs, and ERs, and offices
while stabilizing facial fractures, removing third molars, performing bone grafting
and osteotomies, placing implants, and excising soft and hard tissue lesions. To the
benefit of patients, society now has blood banks, vessel repair, catheter-placed
42 M. H. Goldberg

Fig. 2 Ambroise Paré performing a leg amputation of a wounded soldier in the field of battle
(illustration for “La Ciencia Y Sus Hombres” by Louis Figuier; D Jaime Seix, 1876)

hemostatic emboli, pinpoint electrocautery, and collagen plugs. Over four centuries
later, humanity owes a considerable debt to Ambrose Paré.
Five things are proper to the duties of a churgian. To take away that which is
superfluous. To restore to those places, such things as are displaced. To separate
those things which are joyned together. To join those which are separated. To supply
the defects of nature. (from “THE EPISTLE DEDICTORIE TO HENRY THE
THIRD, THE MOST CHRISTIAN KING OF FRANCE AND POLAND” 8
FEBRUARY ANNO DOMINI 1579, PARIS).
Ambroise Paré’ possessed all the attributes of a great surgeon – manual skill,
experience, judgment, courage, and compassion. He was a very humble man as
evidenced by his most often recognized quote found on the base of his statue in
level – “Je le pansy, Dieu le guérit” (I dressed him, God healed him) (Bishop 1995b).

3 Anesthesia – Horace Wells

Horace Well was born on January 21, 1815, in Hartford, Vermont (Fig. 3). The son
of prosperous farmers, he was educated in New Hampshire and Massachusetts
(Gordon 2000). At the age of 19, he moved to Boston for a 2-year apprenticeship in
The Three Pillars of Surgery 43

Fig. 3 Dr. Horace Wells

1815–1848. (Reproduced
without alteration, public
domain image)

dentistry. Upon completing his apprenticeship, Wells then moved to Hartford,

Connecticut, where he started a lucrative dental practice (Jacobson 1995).
Fast forward to December 11, 1844, in Hartford, Connecticut, a 29-year-old den-
tist reluctantly agreed to accompany his wife to a theater where Gordon Quincy
Colton, an itinerant showman and “medicine man,” was performing. Colton admin-
istered nitrous oxide, contained in a leather bag, to volunteers from the audience
who, while “analgesialized,” unwittingly stumbled and tripped across the stage to
the delight of the locals. One of the participants, Samuel A. Cooley, an apothecary
clerk, struck his leg against a chair but did not cry out nor, when questioned after-
ward by Wells, did he recall the injury (Haridas 2013).
“Chance favors the prepared mind.” Put otherwise, keen observation and rational
deduction often lead to profound revelations and discoveries. That young dentist,
Horace Wells, having observed, then reasoned that the nitrous oxide must have
obtunded that man’s pain, a glorious feat never before accomplished, except by
large doses of laudanum (opium).
The following day in his office, Wells wittingly and willingly underwent extrac-
tion of one of his own teeth, with nitrous oxide as the successful anesthetic. In
attendance were his practice partner William Morton and the wielder of the forceps,
44 M. H. Goldberg

John Riggs (Haridas 2013). It was certainly one of the greatest advances, perhaps
the greatest gift to mankind, in the history of surgery.
The widely held tradition is a subsequent attempt by Wells to anesthetize a
patient during a longer procedure – excision of a mass – in the amphitheater of the
Massachusetts General Hospital (MGH) failed. That patient’s screams did not shock
the jaded assembled black, frocked-coated surgeons who then collectively stamped
their feet and shouted “humbug, humbug,” a mid-nineteenth-century term for decep-
tive behavior.
There is no primary evidence for this tradition. More likely, a medical student
had a tooth extracted with nitrous oxide in a public hall on Washington St. in Boston.
The failure of the procedure in front of medical colleagues indeed is true. Wells
attributed the failure of achieving pain-free surgery was due to removing the nitrous
oxide bag too soon. When the medical student who was having his tooth extracted
was questioned, he stated that he had not felt any pain (Jacobson 1995; Haridas 2013).
Two years later, Morton successfully demonstrated the use of ether at the
MGH. This news was rapidly transmitted, overcoming brief initial doubts. In
England, its demonstration was greeted not with “humbug” but with the accolade
“this is no Yankee dodge” (lie).
Disappointed by his failure to receive credit for his discovery of anesthesia,
Wells left Hartford, his family, and his practice for New York, where he wandered
the streets, certainly depressed, perhaps psychotic and was arrested for assault. He
was imprisoned in the Tombs, the ancient, infamous, and aptly named Manhattan
prison. There on January 24, 1848, at age 33, he committed suicide with a razor
(Haridas 2013). In the early 1960s when I was an OMFS resident at Bellevue
Hospital in New York City, my fellow residents and I frequently treated patients on
the locked prison ward, those sent, shackled, from the still extant Tombs.
Perhaps Wells was predestined for greatness. Surely, his gift to mankind ended
millennia of unbearable pain, but his postdiscovery life was a tragedy, although not
quite a Sophoclean Greek Tragedy. His ultimate fate may have been predetermined
by his own flaws and fragility, the outcome perhaps predictable, even if not by a
Delphian Oracle or a Cassandra.
Morton has been described by many historians as an inflexible, narcissistic, anti-
social, financial con man who had hoped (but failed) to gain great profit from ether.
He died in 1868. Riggs later investigated and published the first accurate description
of periodontal disease, known for many decades thereafter by the eponym Riggs’
disease.
The debate continues about who really discovered general anesthesia – Long,
Wells, Morton, Jacobson, or others. Sir Humphrey Davy discovered nitrous oxide in
1798 and felt that it had the potential to be used to alleviate surgical pain, but it was
Wells that conceived of its application according to a letter written by Riggs
(Menczer and Jacobson 1992). Long claimed to have performed surgery in 1842 but
failed to publish his work until after the success of Wells and Morton. Although
ether had been used earlier than nitrous oxide, nitrous oxide has proven more effec-
tive because of its low risk and analgesic properties and continues to be used today.
The Three Pillars of Surgery 45

Three days after the death of Wells, the Societé Mḗdicale Française “recognized
Dr. Horace Wells as the first person to discover and successfully apply vapors or
gases for painless operations” (López-Valverde et al. 2011). Furthermore, in 1864,
the American Dental Association passed a resolution “to Horace Wells of Hartford,
Connecticut belongs the credit and honor of the introduction of anesthesia in the
United States” (Ring 1985c). The debate should be over.
A bronze plaque on the outside wall of an office building close to the old State
Capitol in Hartford commemorates the site of Wells’ office and the monumental
first-anesthetized surgery. In a park adjacent to the present capitol building, a true
monument, a statue of Horace, stands appropriately on a pedestal (pillar). His grave,
the plaque, and the statue are preserved by the Horace Wells Club, a 40-member
group of dentists who meets annually, early in December, at a black-tie dinner to
pay homage to Wells.

4 Asepsis – Joseph Lister

The development of surgery ground to a halt and could go no further until the prob-
lem of surgical infection could be resolved. Surgeons knew how the body worked,
they could control blood loss, and they even could put a patient to sleep while they
operated (Hollingsham 2008b).
The third pillar which supports our twenty-first-century surgical edifice is asep-
sis, the prevention and therapy of surgical infection. Of this triad of hemostasis,
anesthesia, and asepsis, only the last of these remain a persistent and controversial
issue, i.e., the overuse and abuse of antibiotics. The incision and drainage (I&D) is
probably the oldest surgical procedure performed many millennia ago by tribal sha-
mans or witch doctors using sharp sticks or splinters of flint. Our more contempo-
rary predecessors, barber-surgeons, may have utilized metal lancets, but the cause
of infection remained a mystery shrouded in superstition.
In 1674 in Delf, Holland, while utilizing a primitive microscope (lenses, mirrors,
candles), Antoine Van Leuwenhoek discovered microbes. This 42-year-old linen
draper and amateur naturalist was shocked to find “tiny moving animals” observed
in a drop of saliva and food debris which he had scraped from his teeth! It was a
great revelation to the very early and quite small scientific community of his era, but
its relationship to disease and infection could not even be theorized after 15 centu-
ries of (Greco-Roman) Galen’s fixed ingrained dogma which taught that illness was
caused by an imbalance of blood, phlegm, and bile. Like his contemporaries of the
seventeenth-century Enlightenment (Descartes, Spinoza, Locke, and Newton), Van
Leuwenhoek had opened and expanded man’s comprehension of the universe:
Galileo had done so with a telescope, Van Leuwenhoek with a microscope.
Centuries earlier, physicians of the Arab world were far more advanced than their
Middle Ages European contemporaries. Notable was Moses Maimonides, the
twelfth-century physician, astronomer, theologian, and philosopher: “You must
46 M. H. Goldberg

accept the truth from whatever source it comes.” He observed and reasoned that the
frequency of infection might be diminished if physicians and surgeons were to wash
their hands before examining or treating patients. Even if his discoveries and writ-
ings, in Arabic and Hebrew, had reached Europe, it is highly unlikely that they
would have been accepted.
Nor later was the clinical experiment of Ignaz Semmelweis, a Hungarian obste-
trician practicing (1848) at the Allegmeines Krankenhaus in Vienna. Appalled by
the high (22%) death rate from childbirth puerperal fever, he observed and reasoned
that something other than “airborne miasmas” might be the cause, perhaps from the
hands of medical students who were on call to assist at childbirth, often coming
directly from fresh autopsies of cadavers who frequently had expired from that era’s
most common cause of death: infections. He instructed the students to wash their
hands prior to examining the mothers or delivering their babies, and the infection
rate fell to 1%. Unfortunately, Semmelweis’s work was not translated into English
until 1941 (Ellis and Abdella 2019b).
His fellow obstetricians refused to accept the obvious conclusion from his suc-
cessful clinical trials. Because of age-old rigid dogma, jealous professionalism, and
the unpopularity of Hungarians in Vienna in 1848 – the “year of revolutions” in
Europe – Semmelweis was committed to an asylum, though later released. Ironically,
he died as the result of an infection of a cut sustained while performing an autopsy.
In one of medicine’s most unlikely coincidences, the conquest of puerperal fever
occurred simultaneously in Boston, Massachusetts. Physician Oliver Wendell
Holmes Sr., also a poet and writer (“a moment’s insight is sometimes worth a life’s
experience”), discovered and published his handwashing experience preventing
“childbed fever,” which was accepted by his peers and was widely distributed.
Although Louis Pasteur (“chance favors the prepared mind”) and Robert Koch
(four postulates) in the mid-late nineteenth century had proven, beyond any doubt,
that microbes were the causative agents of infection, the Germ Theory was only
hesitantly accepted. Even the great Virchow, originator of the concept of cells and
cellular pathology, rejected the theory because he was “sure” that the etiology of
infection came from within cells rather than from invading microorganisms. He was
unwilling to challenge his own new “truths.”
In 1867, British surgeon Joseph Lister introduced the concept of sterile surgery
by utilizing a dilute solution of carbolic acid to disinfect traumatized tissue or prior
to surgical incision, as well as for cleaning surgical instruments. He had observed
that carbolic acid was being used to control the odor from sewage, and he reasoned
that the chemical would be safe because it had no apparent deleterious effects on
livestock.
Joseph Lister was born in Upton, Essex, England, of Quaker parents (Fig. 4). His
father was a wine merchant and the inventor of a microscope that did not distort
color (“achromatic” microscope) (Brand 2010). Lister came by his interest in
research and science as a child. Because of his Quaker religion, Lister was unable
to attend either Oxford or Cambridge. He attended the University College of
London, entering the undergraduate curriculum at age 16 in 1844 and graduating
from the medical school in 1851 (Schneider 2020a).
The Three Pillars of Surgery 47

Fig. 4 Joseph Lister at age

69, taken during the
meeting of the British
Medical Association in
Liverpool, 1896.
(Reproduced without
alteration, public domain
image)

For centuries, compound fractures of the limbs had been treated by early amputa-
tion to avoid osteomyelitis and death from sepsis. Lister’s first use of his dogma
defying revolutionary idea (1865) was on 11-year-old James Greenlees who sus-
tained a compound fracture of the leg. The normal progression of open fractures
was infection, amputation, further infection, and then death. Lister applied frequent
dressings soaked in carbolic acid: no infection, no necrosis, no osteomyelitis, no
sepsis, and no death! After 6 weeks of immobilization, James was discharged,
intact, and aseptic (Hollingsham 2008c; Fitzharris 2017).
After successfully treating 9 of 11 compound fractures, Lister published his
work in 1867. This was at a time when the death rate from amputation was 25–60%,
the more common course of an open fracture (Bishop 1995c). Lister’s techniques
were put to the test by the Germans in the Franco-Prussian War (July 1870–May
1871). The end result was that “for the first time in warfare history, fewer men died
of infection than from the trauma itself” (Schneider 2020b).
However, the concept of aseptic surgery was much slower to gain acceptance by
surgeons than had been the introduction of general anesthesia almost a quarter of a
century earlier. In the United States, one of the staunchest advocates of Lister’s
innovative antisepsis was William Halsted who had returned (1880) from surgical
training in the great hospitals and Krankenhausen of Europe. Initially at Bellevue
48 M. H. Goldberg

Hospital in NY City and later at the John Hopkins Hospital in Baltimore, Maryland,
he developed techniques for hernia repair and mastectomy while also performing
the first mandibular nerve block, utilizing cocaine (procaine was not synthesized
until 1905). He also formalized the pyramidal residency training program, a great
educational leap forward from the traditional pay-as-you-learn (observe) surgical
apprenticeships. He also introduced rubber (sterile) gloves – to protect the hands of
his scrub nurse from the carbolic acid. He later married her.
During the 1880s, Halsted traveled from New York to Albany to treat a middle-­
aged woman who was dying of acute, severe cholecystitis, complicated, no doubt,
by dehydration and electrolyte imbalance – an unknown entity in that era. On her
kitchen table, using open-drop ether (Morton), antisepsis (Lister), and ligation of
blood vessels (Paré), he performed the first surgical removal of gallstones and drain-
age of the gallbladder. His mother survived!
Certainly, a history of the great advances in surgical infection control must
include Alexander Fleming and his chance discovery of penicillin (1928), the “won-
der drug,” thus creating the antibiotic era, now including multiple generations of
cephalosporins, quinolones, macrolides, and aminoglycosides, while penicillin
begat ampicillin, which begat amoxicillin, which begat Augmentin, etc.
Unfortunately, his momentous history-changing observation of fungal growth on an
agar plate languished in an obscure journal of laboratory bacteriology until first
used clinically – in 1940, by Florey and Chain, to treat a young British policeman
who was septic from an infected facial wound which had been caused by a rose-
bush thorn.
Lister died in 1912. In 1883, he was created a baron by Queen Victoria, becom-
ing the first surgeon to obtain a peerage (Ellis and Abdella 2019c). Joseph Lister
revolutionized the practice of surgery by removing the almost inevitable complica-
tion of postoperative infection, introducing scientific principles to surgical investi-
gation. He elevated the rise of surgery from a craft to a professional science (Newson
2003; Horwitz and Deupree 2012).

5 Summary

Speculatively, how many lives were lost or severely diminished during those
12 years (1928–40)? Or what if Fleming had simply discarded that contaminated
petri dish rather than deducing that the penicillin fungus had destroyed its bacterial
colonies? What if Lister’s patients had sustained their injuries just a few years ear-
lier: perhaps hundreds of thousands of lives and limbs might have survived the
American Civil War? What if Horace Wells had not attended that performance?
Indeed, what if Paul Ehrlich (1910) had discontinued his years of methodical search
for a chemical cure of syphilis at compound #605 rather than progressing to #606
(Salvarsan), thus creating a new therapeutic science – chemotherapy.
The “what if” school of historical thought and speculation cannot definitively
answer its own questions, but the common denominators in all of these tales of great
The Three Pillars of Surgery 49

leaps forward taken by the giants of their eras are open innovative minds, keen
observation, and willingness to challenge ancient or indefensible dogma or even
hostility and failure. Some achieved great fame in their lives while others suc-
cumbed without it, but they have become immortal by endowing so much to so many.
Are great historical advances and changes direct linear trajectories, or are they
just chance encounters – or perhaps even providential predetermination? Is each
innovator unique, or do they all stand, to some degree, on the intellectual “shoul-
ders” of those who preceded them? How much is due simply to being at the right
place at the right time? Unanswerable questions, but the solid pillars and glorious
legacies remain for we who have inherited them.

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Anesthesia

Andrew R. Emery and Leonard B. Kaban

1 Introduction

The discovery of anesthesia has been recognized as one of the most significant dis-
coveries in the history of mankind. Massachusetts General Hospital (MGH) surgeon
Henry Bigelow, the assistant surgeon at the first demonstration, claimed that anes-
thesia was “medicine’s greatest single gift to suffering humanity” (Viets 1949). The
success of inhalation anesthesia received widespread attention, interest, and rapid
adoption in the practice of surgery because it was the only successful method of
pain relief available for surgical patients. In the future, other routes of administra-
tion for general anesthesia and local anesthesia would also have a significant impact
on pain relief. This chapter summarizes the history of general and local anesthesia
and neuromuscular blockade and concludes with the concept of balanced anesthesia.

2 Inhalation Anesthetic Agents

Inhalation anesthesia is frequently what comes to mind when the origins of anesthe-
sia are discussed. Despite a robust account of the pioneering presentation of ether in
1846 by William Morton, it is also important to consider the preceding years and
scientific discoveries that set the stage for such a monumental achievement.
The earliest attempts at inhalation anesthesia date back to the middle ages when
mixtures of mandrake, henbane (i.e., a source of scopolamine), and other hallucino-
gens were consumed (Carter 1999). Although some believe that these substances

A. R. Emery (*) · L. B. Kaban

Oral and Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental
Medicine, Boston, MA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 51

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_5
52 A. R. Emery and L. B. Kaban

would have been most likely consumed by mouth, references made to inhaled
vapors suggest that this likely represented primitive inhalation anesthesia. Despite
the discovery of these hallucinogenic alkaloids, it would be centuries before true
anesthesia, where patients remain immobile after a noxious stimulation, was actu-
ally discovered.
In 1275 CE, a well-known alchemist, Raymond Lully, created a solution of ethyl
ether named the “sweet oil of vitriol” by mixing sulfuric acid and wine (Davison
1949). This discovery was recapitulated a few hundred years later when the collec-
tive writings of German physician Valerius Cordus, describing similar solutions,
were published by Conrad Gesner in 1561 (Leake 1925a). These well-documented
accounts of “sweet oil of vitriol” have led some historians to credit Cordus as the
discoverer of ether. Around the same time, Paracelsus, who was a Swiss alchemist
and physician, may have also discovered ethyl ether’s properties. Alternatively, he
found out about them from Cordus during his visits to Nuremberg and Leipzig.
Paracelsus went on to describe the incapacitating and transient effects of ether on
chickens but failed to realize potential surgical implications before dying in 1541
(Leake 1925a). A few years later, Italian philosopher and polymath Giambattista
della Porta, also known as John Baptista Porta, contributed a collection of writings
known as “Natural Magick” published in 1558. He described the ability to induce a
“profound sleep” after inhaling certain vapors (Porta 1658). These historic refer-
ences to inhalation anesthesia likely set the stage for what was to follow in the
eighteenth and nineteenth centuries.
The next breakthrough came from Joseph Priestly, an English minister, who in
1772 heated iron filings with nitric acid producing nitrous oxide. He called this gas
“dephlogisticated nitrous air.” In the ensuing years, Priestly discovered other gases
or “airs” including carbon dioxide (1772) named “combined fixed air,” ammonia
(1773) named “alkaline air,” and finally sulfur dioxide (1774) named “vitriolic air”
(West 2014a). Samuel Mitchell, an American physician and politician, described
the anesthetic effects of nitrous oxide in 1795 (Bergman 1985). He also suggested
that nitrous oxide might represent the contagion leading to all infectious disease
(Riegels and Richards 2012). Mitchell’s writing caught the attention of Humphry
Davy, an American chemist and inventor, whose skepticism of Mitchell’s contagion
theory led him to investigate nitrous oxide himself (Bergman 1985). In 1798, at the
invitation of Thomas Beddoes of England, Davy started working at Beddoes
Pneumatic Institute, devoted to treating pulmonary tuberculosis (Leake 1925b).
Davy became the first to demonstrate that gases could liquify by pressurizing them
(Zimmer 2014). Davy also discovered the potential for nitrous oxide to eliminate
pain during surgery in 1800, and he subsequently described his personal use of
nitrous oxide for wisdom tooth pain (Riegels and Richards 2012). Davy experi-
mented with inhaling carbon dioxide demonstrating that a 30% solution could pro-
duce narcosis associated with “a degree of giddiness and an inclination to sleep”
(Riegels and Richards 2012). The change in sensation supported the hypothesis that
gases had the ability to change human consciousness.
In 1805, a Japanese surgeon named Seishu Hanaoka gave an oral mixture of
herbs that induced general anesthesia in a patient, allowing him to perform a
Anesthesia 53

successful mastectomy (Ball and Westhorpe 2011). Although not a gas, the oral
elixir produced an anesthetic effect which facilitated a painless operation nearly
40 years prior to Morton’s demonstration of ether. Unfortunately, this discovery was
not shared with the world probably because the shogun of Japan, Tokugawa
Yoshimune, would not allow its release.
In 1818, Humphry Davy’s successor and English scientist, Michael Faraday, pub-
lished an article describing similarities between the effects of ether and nitrous oxide
(Bergman 1992). Faraday suggested that ether had recreational benefits similar to
nitrous oxide. In the 1830s, recreational ether use, referred to as “ether frolics,” became
a popular form of social entertainment (Short 2014). Despite the sensory altering
effects of these gases, it was not appreciated that they could be used for elimination of
pain during surgery. With ether and nitrous oxide both under study by scientists and
being used for recreational purposes, another inhaled gas, chloroform, was discovered
by Frenchman Eugene Soubeiran in 1831. German scientist Justus von Liebig inde-
pendently discovered chloroform in 1832 (Kyle and Shampo 1997). However, the idea
to use chloroform for anesthesia would not be realized until after the demonstration of
ether in 1846. In January of 1842, American medical student William Clark recorded
the first use of ether to perform a dental extraction, and in March of the same year,
American surgeon Crawford Williamson Long used ether to painlessly remove a
tumor from the neck of his patient, James Venable (Desai et al. 2007).
On December 10, 1844, Gardner Colton, who had dropped out of medical school
to put on nitrous oxide demonstrations, displayed the effects of nitrous oxide on
several volunteers in Hartford, Connecticut. A practicing dentist of Hartford named
Horace Wells was present for the demonstration. After observing a volunteer injure
himself with little evidence of pain, Wells saw the potential for analgesia and anes-
thesia (Desai et al. 2007). Dental surgeons, at that time, were desperate for remedies
to make tooth extractions less painful. Horace Wells then arranged for one of his
own molars to be extracted the next day by John Riggs with Gardner Colton admin-
istering nitrous oxide (Desai et al. 2007; Smith and Hirsch 1991; Haridas 2013).
After a few weeks of practicing with nitrous oxide on 12–15 patients, Wells traveled
from Hartford, CT, to Boston, MA, in January of 1845 in hopes of demonstrating
his discovery to physicians there (Haridas 2013).
As an aside, Wells initially trained as an apprentice under Nathan Cooley Keep,
a revered dental surgeon in Boston, before returning to Hartford to start his practice
around 1836 (Beecher and Ford 1848). There were no formal dental schools at that
time. Morton, who was 4 years younger than Wells, first met Wells in Massachusetts
while Wells was on a business trip and before Morton was interested in dentistry
(Beecher and Ford 1848). In 1841, when Morton was 21 years old, he sought to
study dentistry and went to Hartford, CT, where he learned from Wells as noted by
the payment Wells documented in his day book (Archer 1944). Wells and Morton
eventually partnered in Hartford, and when Wells invented a noncorrosive dental
solder in 1843, they went to Boston to promote it and open another office (Beecher
and Ford 1848). Their partnership dissolved in 1844, but they remained friends, and
following in Wells footsteps Morton would also seek out Nathan Cooley Keep for
special apprentice-style training.
54 A. R. Emery and L. B. Kaban

Morton would eventually help connect Wells to John Collins Warren, the
surgeon-­in-chief at Massachusetts General Hospital (MGH), who agreed to intro-
duce Wells to his class of Harvard Medical students after a lecture he was giving, for
a demonstration of nitrous oxide (Smith and Hirsch 1991; Haridas 2013; Guralnick
and Kaban 2011). Unfortunately, the nitrous was withdrawn too soon from the stu-
dent volunteer who admitted to feeling pain as Wells extracted one of his teeth
(Urman and Desai 2012). According to Morton, the audience “laughed and hissed,”
leaving Wells utterly embarrassed (Haridas 2013). This failure would eventually
cause Wells to spiral into depression before taking his own life in 1848 (Guralnick
and Kaban 2011).
Despite Wells’ failed demonstration, Morton probably realized the potential of
his attempt (Beecher and Ford 1848; Guralnick and Kaban 2011). Morton’s mentor
Nathan Cooley Keep, the most respected and skilled dental surgeon of the time in
Boston, likely encouraged him to continue using ether, and Keep likely called upon
his friend and Harvard Professor of Chemistry, Charles Thomas Jackson, for help
(Guralnick and Kaban 2011; Urman and Desai 2012; Kaban and Perrott 2020).
Jackson is believed to have suggested to Morton that he should use sulfuric ether
instead of commercial ether (a common cleaning fluid) to produce anesthesia
(Guralnick and Kaban 2011; Lopez-Valverde et al. 2011). Morton experimented
with ether and tried it in animals and eventually on a patient, Ebenezer H. Frost,
from whom he successfully removed a tooth on September 30, 1846 (Guralnick and
Kaban 2011; Urman and Desai 2012). Morton wanted to keep the identity of the gas
a secret in hopes of collecting royalties later, but MGH surgeon-in-chief Dr. John
Collins Warren resisted this by delaying the initial demonstration until Morton
revealed the name of the drug to him (Guralnick and Kaban 2011). Finally, on
October 14, 1846, Morton was invited to MGH by Warren to demonstrate his anes-
thetic technique (Guralnick and Kaban 2011; LeVasseur and Desai 2012). Morton,
who only had 2 days to prepare, scrambled to the last minute to finalize his conical
glass inhaler with the help of local instrument maker Joseph Wightman (Viets
1949). Ultimately, he arrived late for the 10 AM demonstration but successfully
anesthetized the patient, Edward Gilbert Abbott, for the ligation of the feeding ves-
sels of a congenital vascular malformation performed by Warren (Vandam and
Abbott 1984) (Fig. 1). Warren famously turned to the audience and uttered,
“Gentlemen, this is no humbug” (Leake 1925b; Guralnick and Kaban 2011).
However, some physicians remained skeptical of Morton’s technique given the
superficial nature of the operation, so Morton tried again to validate his technique
by providing ether for the removal of a fatty tumor, but there were doubters once
more. Morton again provided anesthesia on November 7, 1846, this time for a knee
amputation performed by surgeon George Hayward, and his success left skeptics
convinced. Thus, Morton’s work was validated at last (Guralnick and Kaban 2011).
Morton and Jackson submitted their joint patent for “surgical insensibility by
means of sulphuric ether” on November 12, 1846 (Yang et al. 2018). Eventually,
Morton, Jackson, and Wells would all oppose each other in search of recognition for
the roles they each respectively played in the discovery of ether anesthesia (Leake
Anesthesia 55

Fig. 1 Robert Cutler Hinckley oil on canvas painting from 1893 entitled The First Operation with
Ether (Reprinted with permission from the Harvard Medical Library in the Francis A. Countway
Library of Medicine, Boston, Massachusetts)

1925b). Years later, in 1849, Morton would appeal to Congress for a $100,000 grant
for his contributions of ether anesthesia, but primary opposition from Keep, as well
Jackson, would ultimately foil Morton’s chances of financial remuneration (Leake
1925b; Guralnick and Kaban 2011).
On November 11, 1846, just 3 weeks after Morton’s initial demonstration, ether
was being used in Scotland for amputations (Viets 1949). Soon after that, Robert
Liston, the preeminent surgeon in London, used ether for surgery with success and
much surprise (Pieters et al. 2015). By January 19, 1847, Scottish obstetrician James
Simpson became the first person to use ether for labor (Dunn 1997). On April 11,
1847, dentist Nathan Cooley Keep became the first to use ether for obstetric anes-
thesia in the United States. He administered ether to the wife of American poet,
Henry Wadsworth Longfellow, for the delivery of their daughter Fanny in their
home on Brattle Street in Cambridge, MA (Guralnick and Kaban 2011; Dunn 1997).
A year later, on November 4, 1847, Simpson and colleagues experimented with
various vapors in search of something less pungent for pregnant patients and came
upon chloroform (Kyle and Shampo 1997). Simpson soon popularized chloroform,
making it the British anesthetic of choice, while ether remained the preferred
56 A. R. Emery and L. B. Kaban

anesthetic in the United States (Kyle and Shampo 1997). John Snow, an English
physician known as the father of epidemiology for his work identifying the water
pump which was the source of the cholera epidemic in London, learned about these
demonstrations of ether and chloroform and began studying anesthesia himself
(Leake 1925b). In 1847, he described the five stages of anesthesia (Thornton 1950),
and in 1853, he administered chloroform to Queen Victoria during childbirth, end-
ing moral opposition to the relief of pain and generating greater acceptance of anes-
thesia use (Kyung et al. 2018).
Inhaled anesthetics would soon spread globally by the ships’ captains and doc-
tors within a year after the first demonstration, driving innovation and scientific
investigation (Ellis 1976). Second-generation anesthetic gases were eventually pro-
duced including ethyl chloride (1894), ethylene gas (1923), and cyclopropane
(1933) (Whalen et al. 2005). In the 1940s, due to the ongoing covert Manhattan
project, attention was turned to fluorine chemistry leading to the production of fluo-
rinated anesthetics including halothane (1951), methoxyflurane (1960), and enflu-
rane (1963). Enflurane was then followed by isoflurane in the 1980s, which was
eventually replaced by sevoflurane and desflurane in the 1990s (Wang et al. 2020).
In the ensuing years, increased understanding of the mechanisms of action and
metabolism of the inhaled anesthetics, patient factors, and the effects of the type of
surgery being performed have guided the indications for the uses of various anes-
thetic gases.

3 Intubation and Inhaled Anesthesia Technology

In addition to the pharmacologic discovery of inhaled anesthetics, it is also impor-

tant to consider the technological advances that kept pace and occasionally drove
inhaled anesthesia innovation.
The development of techniques for surgical airways dates back as early as
3600 BCE, depicted by the healing tracheostomy wounds seen on Egyptian hiero-
glyphics (Rajesh and Meher 2012). In the second century CE, despite the Greek
physician, Galen, describing the necessity of breathing to keep the heart beating, it
was not until 1543 when Andreas Vesalius described opening the trachea of an ani-
mal to provide ventilation that interest in this subject increased (Slutsky 2015). In
1546, the first successful surgical airway on record was done by Antonio Musa
Brassavola for a tonsillar obstruction; however, the term “tracheotomy” was not
coined until Thomas Fienus first used it in 1649 (Rajesh and Meher 2012). A few
decades later, in 1667, English scientist, philosopher, and polymath Robert Hooke
demonstrated that blowing fresh air into the lungs of dogs that were not breathing
was life-sustaining (West 2014b). Thus, the pure movement of the lungs was not
itself essential to life, nor was it driving the movement of blood throughout the
lungs or body. This realization suggested that life was sustainable with just air
exchange in the lungs, whether by natural or artificial means.
Anesthesia 57

In 1754, an English obstetrician named Benjamin Pugh described one of the first
airway devices: an air-pipe made of tightly coiled wire for resuscitating neonates
(Szmuk et al. 2008; Baskett 2000). In 1760, Buchan used an opening in the wind-
pipe to aid in human resuscitation (Szmuk et al. 2008). Later, in 1788, Englishman
Charles Kite introduced a curved metal cannula into the trachea of drowning vic-
tims to help resuscitate them (Szmuk et al. 2008).
In 1829, English physician Benjamin Guy Babington published on his “glotto-
scope,” which consisted of a tongue depressor speculum to retract supraglottic tis-
sues out of view and a series of mirrors used to visualize the larynx (Pieters et al.
2015). The term “laryngoscope” was adopted later by fellow colleague and physi-
cian Thomas Hodgkin, who is best known for his work on Hodgkin’s disease
(Pieters et al. 2015). Ultimately, the direct laryngoscope would be developed in
1910 by American physician Chevalier Jackson (Pieters et al. 2015).
In 1874, Jacob M. Heiberg, a surgeon from Norway, described the jaw thrust
maneuver for opening up airways (Matioc 2016). In 1876, Alfred Woillez developed
a manual ventilator, which was later replaced by the iron lung (Slutsky 2015).
Eventually in 1885, using high-pressure oxygen cylinders with high-pressure
nitrous oxide, the SS White Company patented the first anesthesia machine (Bause
2009). In 1893, Austrian physician Victor Eisenmenger described using an inflat-
able cuff around an endotracheal tube paving the way for the designs used today for
endotracheal intubation (Gillespie 1946). In 1967, English physician Ian Calder
performed the first fiber-optic bronchoscopy (Pieters et al. 2015), and in 2001,
Canadian surgeon John Pacey invented the first commercially available video laryn-
goscopes known as the GlideScope (Pieters et al. 2015).
In addition to technical advances, in 1895, Harvey Cushing and Amory Codman,
both Harvard medical students, first proposed the idea of keeping an anesthesia
record, which included information such as the pulse, respiratory rate, depth of
anesthesia, and amount of anesthetic given (i.e., ether) (Fisher et al. 1994), which
remains standard practice today.

4 Parenteral Anesthesia

Some of the most important and frequently used anesthetics today are those
intravenously administered. While the separate historical timelines of inhalation,
local, and parenteral anesthesia can be thought of as parallel themes at times unfold-
ing simultaneously, the discovery of parenteral anesthesia arguably started earlier
than the rest.
It seems most appropriate to start the story of parenteral anesthesia with the
establishment of intravenous access. The earliest record of intravenous access for
medication administration appears to date back to 1656 when the English architect
Christopher Wren performed a cutdown to access the leg vein of a dog. Wren
58 A. R. Emery and L. B. Kaban

delivered ale via a goose quill as the needle and animal bladders as the syringe
(Dorrington and Poole 2013; Dagnino 2009), leaving the dog transiently senseless
before later regaining full consciousness and surviving. Johann D. Major, a German
graduate of Padua University, tried this technique on humans in 1662 (Barsoum and
Kleeman 2002; Foster 2005), but the resulting mortality paralyzed the scientific
advancement of this technique for another 200 years until Adam Neuner developed
a syringe in 1827 while studying cataract surgery (Blake 1960). From 1827 onward,
the concentrated efforts of many individuals on improving syringe and needle
design were paramount to the future of both local and parenteral anesthesia.

4.1 Opioids

General anesthesia has been defined as a state in which a patient is rendered amnes-
tic, unconscious, immobile, and free of pain (Dodds 1999). Although inhalation
anesthetics produce rapid unconsciousness with rapid recovery, opioids in high
enough doses can also produce similar anesthetic effects, but often with a longer
recovery period. Opioids are effective because of their strong analgesic effects,
which blunt the pain inflicted by surgical incision, dissection, and manipulation,
thereby reducing the reflex stress response to pain which results in withdrawal from
the stimulus, tachycardia, and hypertension. As a result, opioids are powerful anes-
thetics or anesthetic adjuncts depending on their dose and the circumstances of
their use.
Opium is a substance derived from the poppy plant and well known since
3000 BCE in Mesopotamia (Brownstein 1993; The History of Opiates | Michael’s
House Treatment Center 2020). After thousands of years, morphine was extracted
from opium by Friedrich Sertürner in 1806 (Schmitz 1985). A few years later in
1832, codeine was identified as an impurity associated with morphine and isolated
for use as an analgesic drug (Eddy et al. 1968). In 1898, heroin (known as diacetyl-
morphine) was commercialized by the Bayer company (Leverkusen, Germany),
also involved in the discovery of aspirin around the same time (Sneader 1998).
Heroin was initially marketed as a cough suppressant with a presumed lower risk of
addiction compared to morphine. However, a decade later, concerns for addiction
and drug dependence would begin challenging the drug’s acceptance. Heroin was
banned in the United States in 1924 (Sneader 1998).
In 1921, hydromorphone was discovered in Germany and found its way into
clinical medicine by 1926 (Murray and Hagen 2005). In 1939, meperidine was syn-
thesized (Batterman and Himmelsbach 1943) about the same time that the long-­
acting opioid, methadone, was synthesized (Fishman et al. 2002). In 1960, fentanyl
was synthesized for the first time, and the synthesis of other fentanyl-like medica-
tions followed: sufentanil, alfentanil, and remifentanil (Stanley 2014). Each of these
medications were integrated into the practice of anesthesia providing the analgesia
component of the balanced anesthesia strategy.
Anesthesia 59

5 Sedative Hypnotics and Other Intravenous Anesthetics

One of the first medications designed for intravenous use was the hypnotic medica-
tion chloral hydrate. It was synthesized by German scientist Justus von Liebig in
1832, but was not introduced into medicine until a fellow German scientist, Oskar
Liebig, did so in 1869 (López-Muñoz et al. 2005).
In 1864, German chemist Adolf von Baeyer synthesized a new class of medica-
tions known as barbiturates when he created malonylurea (Cozanitis 2004). This
eventually led to the synthesis of diethyl-barbituric acid in 1881 and its inauguration
into clinical medicine in 1904 as the first clinically used hypnotic (López-Muñoz
et al. 2005). With diethyl-barbituric acid as the parent molecule, many other itera-
tions were spun off, including one in 1911 called phenobarbital. It was synthesized
by German scientist Heinrich Horlein (López-Muñoz et al. 2005). Many other bar-
biturate variants were developed including butobarbital (1922), amobarbital (1923),
secobarbital (1929), pentobarbital (1930), and hexobarbital (1932) (López-Muñoz
et al. 2005). Thiopental was synthesized from pentobarbital by substituting the oxy-
gen at position 2 for a sulfur group, introducing a new class of medications known
as the thiobarbiturates. This class of drugs was first used clinically by Ralph Waters
in 1934 (López-Muñoz et al. 2005). The addition of sulfur resolved the issue of
muscle movement when the non-sulfonated precursor drug, hexobarbital, was
administered.
After the Second World War, the search for shorter-acting barbiturates resulted in
the discovery of methohexital (López-Muñoz et al. 2005). A distinctive property of
methohexital is the excitability it produces on electroencephalograms, in contrast to
the depressing effects of other barbiturates. This characteristic made it a useful
agent for anesthesia during electroconvulsive therapy (Kadiyala and Kadiyala 2017).
Propofol was discovered in 1973 by Scottish veterinarian John Baird Glen
(2018). Propofol has the advantage of fast onset and decreased postoperative nausea
and vomiting. As a result, it has become one of the most widely used anesthetic
medications, often used without inhalation anesthetics, during total intravenous
anesthesia (TIVA) (White 2008). The introduction (1989) and subsequent popular-
ity of propofol has resulted in significantly diminished barbiturate use in anesthesia.
Other medications important to parenteral anesthesia include the benzodiaze-
pines. The first benzodiazepine, chlordiazepoxide (also known as Librium®), was
discovered in 1960 by Leo Sternbach, a Polish-American chemist working at
Hoffmann-La Roche pharmaceutical company (López-Muñoz et al. 2011).
Additional studies aimed at simplifying the side chains of the chlordiazepoxide
molecule resulted in additional benzodiazepines such as diazepam (1959), oxaze-
pam, alprazolam, triazolam, and midazolam. These medications have been utilized
in anesthesia for their amnestic, anxiolytic, and hypnotic properties (López-Muñoz
et al. 2011).
Another parenteral anesthetic currently in use is ketamine. It was synthesized by
Calvin Stevens, in 1962, to decrease side effects of phencyclidine (PCP) and was
found to lack the cardiac or respiratory depression seen with barbiturates. However,
60 A. R. Emery and L. B. Kaban

emergence delirium, excitability, and addictive potential of this drug have restricted
its use. Situations that require brief sedation, e.g., injured pediatric patients in the
emergency room, remain prime opportunities to utilize ketamine effectively (Gao
et al. 2016). Additionally, etomidate, a rapid-acting anesthetic, was discovered by
Janssen Pharmaceuticals in 1972 (Forman 2011). It has the benefit of rapid onset,
but unfortunately, it has been associated with adrenal suppression, thus relegating
its use to an induction agent for rapid sequence induction (RSI).
More recently, anesthetic discovery has identified dexmedetomidine, approved
by the FDA in 1999, for patients in intensive care units (Gertler et al. 2001). Its use
was then broadened to include surgical patients in 2008 as it provides both sedation
and decreases sympathetic output by stimulating central alpha-2 receptors (Kaur
and Singh 2011).

6 Neuromuscular Blockers

In addition to unconsciousness and analgesia, general anesthesia also requires

patient immobility and muscle paralysis (Dodds 1999). Although inhalation anes-
thetics are useful for producing unconsciousness and opioids best at reducing pain,
neuromuscular blockers are superior at rendering patients immobile and paralyzing
contractile tissues to facilitate surgical manipulation. This permits better conditions
to perform sophisticated operations and reduces overall operating time. Therefore,
neuromuscular blockers add a crucial component to the general anesthesia regimen.
Some of the earliest published accounts of parenteral anesthesia were neuromus-
cular blocker medications, also known as paralytics, that dated back to around
1500 CE. In 1516, Peter Martyr d’Anghera, a historian from Spain, relayed stories
of those who had visited the New World overseas describing the puzzling “flying
death,” in reference to the poison known as curare that was used by natives
(Raghavendra 2002). Wars in Europe stalled further exploration of curare’s poten-
tial until 1735 when Charles de la Condamine, a French explorer, observed
Ecuadorian natives shooting curare-dipped darts from their blowpipes to hunt ani-
mals (Fernie 1964). The acquisition of curare was the first step toward discovering
the potential of neuromuscular blockers.
Curare was then tried in animals including rabbits, cats (Raghavendra 2002), and
donkeys (Birmingham 1999), which survived due to artificial ventilation provided
by bellows inserted into their airways. In 1857, curare’s function as a neuromuscu-
lar junction blocker was discovered (Bowman 2006), and in 1912, German surgeon
Arthur Lawen became the first to use paralytics in surgery (Czarnowski and Holmes
2007). Lawen reported that use of paralytic curarine (an extract from gourd curare)
in combination with ether or chloroform produced the desired level of abdominal
wall muscle relaxation unachieved by other medications (Foldes 1995). In the
1930s, curare was purified and branded under the name Intocostrin, also known as
d-tubocurarine (Ball and Westhorpe 2005), and in 1942, Intocostrin was used on a
Anesthesia 61

patient for the first time, thus officially inaugurating neuromuscular blockade into
clinical practice (Sykes 1992).
In 1946, English researcher Frederick Prescott described his frightening experi-
ence being the first human to voluntarily receive tubocurarine alone without any
other anesthetic agents after which he reported being paralyzed, but sensate to pain
(Prescott et al. 1946). Prescott’s research also found that d-tubocurarine reduced the
shock-like state that often occurred with spinal anesthesia, producing muscle relax-
ation like ether without prolonged postanesthetic recovery and vomiting, and it
saved time as nerve blocks were time-consuming (Prescott et al. 1946).
As the pharmacology of neuromuscular blockers became more robust, so did the
infrastructure that would ultimately help ventilate the paralyzed patient during sur-
gery. Scottish physician John Dalziel in 1983 developed the first negative pressure
respirator in 1838 known as the tank respirator (Kacmarek 2011). In 1911, Johann
Heinrich Draeger introduced the first positive pressure ventilator known as the pul-
motor (Kacmarek 2011). Paralytics and ventilators coevolved as were necessary for
each to remain successful.
In the mid-twentieth century, combinations of drugs to produce anesthesia
became more popular given the growing medications from which to choose. In
1946, Thomas Cecil Gray, an English anesthetist, presented this idea known as “bal-
anced anesthesia” to the Royal Society based on 1500 patients (Shafer 2011). He
described inducing anesthesia with an intravenous agent, giving curare to provide
relaxation and to decrease barbiturate, and an inhaled agent for anesthesia mainte-
nance. His thought was to combine several drugs to create a more advantageous
effect and outcome, and from these descriptions, the multimodal modern anesthetic
approach as we know it was born.
With the balanced anesthesia techniques now realized, scientists and clinicians
turned to newer anesthetic agents and neuromuscular blockers. A depolarizing para-
lytic called suxamethonium, also known as succinylcholine, was introduced into
clinical medicine in 1951 (Raghavendra 2002). In 1964, the non-depolarizing para-
lytic pancuronium was discovered (Raghavendra 2002) and essentially completely
replaced curare for generating neuromuscular blockade. Following this, a number
of other paralytics were discovered, notably vecuronium (1973) (McKenzie 2000),
atracurium (1981) (Raghavendra 2002), mivacurium (1984) (Savarese et al. 2004),
and rocuronium (1994) (Succinylcholine vs. Rocuronium: Battle of the RSI
Paralytics - JEMS 2020). In addition, the Train-of-Four monitor was invented in
1972 allowing clinicians to detect the amount of neuromuscular blockade at any one
time (McGrath and Hunter 2006; Ali’s “train of Four” | Wood Library-Museum
2020), providing even greater control of paralysis in surgery and anesthesia. Despite
the availability of glycopyrrolate and neostigmine for reversal of muscle relaxation,
a new neuromuscular blocker reversal agent known as sugammadex was discovered
in 2001 (Welliver et al. 2008), approved in Europe in 2008 (The Development and
Regulatory History of Sugammadex in the United States - Anesthesia Patient Safety
Foundation 2020) and finally in the United States in 2015 (Drug Trial Snapshot:
BRIDION | FDA 2020).
62 A. R. Emery and L. B. Kaban

As the practice of anesthesia evolves and medications become more targeted, we

find the concept of balanced anesthesia more poignant than ever. Thomas Cecil
Gray’s concept of balanced anesthesia remains the pedagogy behind modern anes-
thesia and serves as the basis on which we now seek to optimize drug combinations
and minimize drug side effects (Shafer 2011).

7 Parenteral and Local Anesthesia Technology

As previously mentioned, the 1820s were transformative years for local anesthesia
with the arrival of the hypodermic syringe (Blake 1960). In 1827, Adam Neuner
developed a syringe-like apparatus through which he was able to inject fluid into the
eyes of deceased corpses to study and practice cataract surgery (Blake 1960).
However, this design included a central stylet, which needed to be removed to inject
fluid requiring more steps to operate (Blake 1960). Not long after, in the 1830s,
French physicians were treating neuralgia in humans by pushing morphine paste
down grooved trocars, functioning as rudimentary syringes (Lawrence 2002). In
1836, vascular nevi were treated by injecting an irritating chemical beneath the skin
first by lancing the skin and then pushing the chemical beneath it with a blunt tip of
a syringe (Blake 1960) representing yet another attempt at hypodermic injection.
Eventually, in 1844, Francis Rynd of Dublin developed a hollow needle in the form
of a cannula within which was a slender retractable trocar required to breach the
skin, marking the first hypodermic needle (Lawrence 2002). By this syringe design,
narcotic liquid followed gravity and was administered under the skin as the cannula
was withdrawn—a functional but not ideal design.
In 1853, Daniel Ferguson, a surgical instrument and truss maker in London,
devised a new syringe design consisting of a glass tube containing an internal
plunger and piston (Blake 1960). The syringe ended in a narrow conical platinum
tube with an oblique opening just proximal to the most distal trocar-like tip. Inside
of that narrow platinum tube was a second slightly shorter tube, also with an oblique
opening that could align with the outer one when the outer one was spun to the cor-
rect position (Blake 1960; Duce and Hernandez 1999). This design did away with
the need for a removable trocar used to puncture the skin before fluid could be
administered. Ferguson’s design was modified by Cooper Forster, a surgeon in
London, with indicators to signal when the aperture was open or closed (Blake
1960). Later in 1853, Edinburgh physician Alexander Wood further modified
Ferguson’s design by calibrating the barrel and creating a threaded tip on the end of
the syringe for attaching a hollow needle with a beveled point (Duce and Hernandez
1999). Wood’s needle that could pierce the skin without needing to lance skin or use
a trocar and his syringe design, published in 1855, earned him the credit for devel-
oping the hypodermic technique. Notably, French veterinary surgeon Charles
Gabriel Pravaz, who simultaneously was developing a hollow metal needle in 1853,
narrowly trailed Wood for the honor of pioneering the original hypodermic syringe
(Lawrence 2002). Interestingly, the term “hypodermic” was not coined until 1865
when proposed by Charles Hunter, who also garnered fame for realizing that
Anesthesia 63

injecting morphine locally caused systemic pain relief, in contrast to Wood who
thought the effects were only local (Howard-jones 1947).
In 1867, as a component of his ongoing work on antisepsis for prevention of
wound and surgical site infection, Joseph Lister described the successful use of
carbolic acid for surgical wounds, which improved both mortality and morbidity
(Schlich 2012; Pitt and Aubin 2012). Lister’s use of carbolic acid is believed to also
have extended to surgical instruments as a means to clean them (Craig 2018; Lister
1870). Later, the idea of using a pressured steam to sterilize instruments would
result in the first autoclave being introduced in 1879 by Charles Chamberland, an
associate of Louis Pasteur (Harvey 2011). Following this invention, in the 1880s
and 1890s, Lister’s assistant Ernst Tavel and Swiss physician Theodor Kocher advo-
cated the use of pressured steam to sterilize instruments, and eventually hypodermic
needles (Schlich 2012; Maclachlan 1942).
However, even 50 years later in the early 1900s, only about 1.8% of the 1039
commonly used drugs in the United States were injectable, a small market for
syringe use. In 1921, after the discovery and use of insulin, there was a subsequent
increase in parenterally administered drugs, making the need for a delivery system
critically important (Lawrence 2002). Needles were reused at the end of the nine-
teenth century and the first half of the twentieth century, and despite attempts at
steam sterilization, they were difficult to clean leading to complications of cellulitis
with reuse (Craig 2018). Attempts to clean these needles included inserting a small
wire to debride the inside followed by either passing them through an alcohol flame
before inserting it, soaking the needle in carbolic solution followed by cleaning with
alcohol or by boiling the needle for a few minutes in water (Hampton 1893). In
1946, the first disposable syringe, made of glass with interchangeable parts, was
developed by brothers Robert Lucas and William Chance (Kantengwa 2020). In
1949, Arthur E. Smith had patented the first disposable hypodermic syringe in the
United States made of glass, eliminating the need to sterilize and reuse syringes
(Levy 2020). In 1955, Roehr products (Waterbury, CT) introduced the first plastic
disposable hypodermic syringe (Levy 2020), which were commonly used by the
1960s (Kravetz 2005). The 1950s also brought about the introduction of many
single-­use items in medicine, including needles (Greene 1986). Disposable syringes
and needles were also mass-produced for the polio vaccination program led by Dr.
Jonas Salk, thus solidifying their utility in medicine (Levy 2020). Since the 1950s,
disposable hypodermic syringes and needles have become the standard of care to
administer drugs parenterally to prevent entry site and hematogenous infection.

8 Local Anesthesia

8.1 Local Anesthesia Drugs

Local anesthesia has become one of the most commonly used methods for alleviat-
ing the pain of surgical procedures and injuries. The injection of local anesthetic
agents is ubiquitous in medicine, dentistry, and other areas of health care from
64 A. R. Emery and L. B. Kaban

operating rooms to outpatient clinics, private offices and in the prehospital manage-
ment of injured patients.
Some of the earliest attempts at pain relief were described by Greek surgeons
applying anodyne and astringent pastes to wounds during the siege of Troy around
1250 BCE (Zorab 2003a). Around 50 CE, a Greek physician named Pedanius
Dioscorides, who eventually wrote a five-volume book on medicine called De
Medica Materia, described mixing Memphitic stone and henbane seeds to smear
onto a surgical site prior to the operation (Belfiglio 2018). This anesthetic paste is
thought to have released carbonic acid producing a cold or “freezing” effect result-
ing in anesthesia of the operative site; this was the first topical anesthetic (Zorab
2003b; Bhimana and Bhimana 2018).
In 1539, the potential use of coca leaf as an anesthetic agent was first described
by Friar Vicente de Valverde, the bishop of Cuzco (Calatayud and González 2003a).
Peruvian literature suggests that coca leaves were chewed and spit into the wounds
of patients to alleviate pain (Chivukula et al. 2014). The local anesthetic mecha-
nisms of cocaine were not well understood but were clearly recognized by the way
it was being used for pain relief. In 1653, the potential anesthetic properties of coca
were revealed by Spanish Jesuit Bernabe Cobo in a paper describing the alleviation
of a toothache by chewing coca leaves (Calatayud and González 2003b).
In 1807, Dominique Larrey, Napoleon’s surgeon during the bloody and cold
battle of Eylau (current day Western Russia), described the numbing effect of cold
snow to produce local anesthesia and reduce the pain of amputations (Zimmer
2014). Although Larrey’s tactic was rudimentary, there were few alternatives read-
ily available as intravenous access was not yet in use. In the 1820s, with the advent
of the early hypodermic syringe, the technology finally caught up to allow localized
medication delivery beneath the skin for analgesic effect (Blake 1960).
In the mid-1860s, before the local anesthetic effects of cocaine had been appreci-
ated for clinical use, British physician Benjamin Ward Richardson used ether spray
to numb the skin (Leake 1925b). Later, Richardson’s ether spray was changed to
ethyl chloride which evaporated more rapidly and produced a faster onset of anes-
thesia. Ultimately, this spray technique would propel topical anesthesia forward,
setting the stage for subcutaneous local anesthesia to follow.
In 1859, nearly 200 years after Cobo’s paper on the numbing effects of coca
leaves was published, German chemist Albert Niemann was the first to isolate pure
cocaine, which he keenly noted caused numbness when placed on his own tongue
(Redman 2011). Vassily von Anrep, a Russian physician also studying cocaine,
described the effects of injecting cocaine into animals commenting afterward that it
should be tested as a local anesthetic. Sadly, his astute recommendation was not
followed, and his brilliant work went largely unnoticed (Yentis and Vlassakov
1999). Finally, in September of 1884, Carl Koller, an ophthalmology resident and
roommate of Sigmund Freud who was also a resident at the Vienna General Hospital,
recognized the significance of cocaine’s local anesthetic potential (Goerig et al.
2012). After witnessing a colleague painlessly cut his tongue while licking cocaine
off a knife, Koller appreciated the significance of the event and realized the potential
of the drug. He soon tested a cocaine solution on frog corneas with demonstrable
Anesthesia 65

decrease in sensation (Goerig et al. 2012). This work was presented to the science
community shortly thereafter and was well received. From then on, cocaine use for
local anesthesia grew rapidly, which also led to the development of many regional
anesthetic techniques.
On December 6, 1884, Richard John Hall and William Stewart Halsted published
a report describing the first nerve block. They used 4% cocaine solution to anesthe-
tize the inferior alveolar nerve of the mandible (Grzybowski 2008). Hall and
Halstead went on to describe the techniques of regional blockade in many other
parts of the body including the facial nerve, brachial plexus, and pudendal and pos-
terior tibial nerves. In 1885, James Leonard Corning published the first report of
spinal anesthesia using cocaine (Wulf 1998). The same year, Corning proposed
using a tourniquet to slow the systemic absorption of local anesthesia (Giovannitti
et al. 2013). It was not until 1903 that Heinrich Braun would modernize this concept
by recommending the use of epinephrine as a chemical tourniquet instead
(Giovannitti et al. 2013), a practice that is standard today.
However, despite cocaine’s growing popularity and use, by 1891, there were 13
deaths and 200 cases of systemic intoxication, raising concern for the safety of
locally injecting cocaine (Murray and f. Cocaine. 1979). Carl Ludwig Schleich
developed standardized local anesthesia infiltration techniques by diluting the topi-
cal cocaine dose for use with hypodermic injection. This technique was safe and
decreased cocaine mortality (Wawersik 1991). His results were presented at the
1892 Congress of the German Society for Surgery in Berlin, but his comments
about infiltration anesthesia being potentially less dangerous than general anesthe-
sia offended the surgeons in the audience. Eventually, however, the merit of his
work was recognized and adopted in Germany.
The increasing mortality from the toxic effects of cocaine and its addictive nature
led a movement to identify alternative substances that could be used as local anes-
thetics. In 1890, Eduard Ritsert, a German chemist, synthesized benzocaine (Brock
and Bell 2012). Unfortunately, its poor water solubility relegated it to use mainly as
a topical anesthetic. In 1903, amylocaine (Stovaine) was introduced but was soon
found to irritate nerves and was promptly replaced. Procaine, better known by its
brand name Novocaine, was synthesized by Alfred Einhorn in 1904. Procaine
remained the main anesthetic in dentistry and medicine until tetracaine was synthe-
sized in 1928. However, tetracaine and procaine were both esters with allergic side
effects and toxicities, as compared to the more tolerable amide compound of lido-
caine, discovered by Nils Lofgren and his assistant, Bengt Lundqvist, in 1948
(Giovannitti et al. 2013). Lidocaine underwent years of clinical testing before finally
being introduced into practice in 1948 following FDA approval. Lidocaine’s toler-
ability would later make it one of the most commonly used local anesthetics, even
today. In 1957, Bo af Ekenstam introduced two more local anesthetics named mepi-
vacaine and bupivacaine (Calatayud and González 2003a; Ekenstam, and af, Egner
B, Pettersson G. 1957). In 1969, Nils Löfgren and Cläes Tegner synthesized prilo-
caine (Löfgren and Tegné 1960), and a few years later in 1972, articaine was first
published in the literature by J. E. Winther (Winther and Nathalang 1972). A more
recent discovery is the 2011 FDA-approved ultra-long-acting anesthetic called
66 A. R. Emery and L. B. Kaban

liposomal bupivacaine (Exparel®) (Drug Approval Package: Brand Name (Generic

Name) NDA 2020). Despite a decrease in the rate of local anesthetic discovery and
innovation over the last several decades, the drive to improve the effects and success
of local anesthesia continues and is evolving.

9 Summary

In conclusion, the story of anesthesia is complex, with simultaneously evolving

themes including inhalation, local and parenteral agents, asepsis, technology, and
neuromuscular blockers. All these combine today to produce balanced anesthesia
safely and appropriately for each patient. Undoubtedly, serendipity played a strong
role at times in the discovery process, but history was made by also seizing the
opportunities provided as demonstrated by William Morton and critical thinking of
John Snow about the science at hand. These factors have driven innovation in anes-
thesia over the last several hundred years and solved one of humanity’s greatest
issues—pain during surgery.

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The Legacy of Maxillofacial Surgery
During the Great War

Shahid R. Aziz and Samina H. Aziz

1 Introduction

World War I, “The Great War,” brought to reality a suffering, violence, and destruc-
tion that were new to the human experience. Historically, the pressure placed on the
medical profession to respond to the care of the wounded during wartime has stimu-
lated the medical sciences into new eras of advancement. It is an unfortunate truth
that war often provides fuel for medical advancement. Trench warfare during World
War I provided surgeons with new challenges in facial trauma management and laid
the cornerstone for modern-day oral and maxillofacial surgery. The work of sur-
geons such as Gillies, Kazanjian, Ivy, Morestin, Valadier, and others provided the
basis for facial reconstruction (Aziz 2001).
The Great War lasted from July 28, 1914, to November 11, 1918. It was a conse-
quence of the assassination the Austro-Hungarian heir Archduke Franz Ferdinand in
Sarajevo by Gavrilo Princip, a Bosnian Serb Yugoslav nationalist. The resulting
Austria-Serbia conflict escalated into two competing alliances: the Triple Entente
(Allied)—consisting of France, Russia, and Britain—and the Triple Alliance of
Germany, Austria-Hungary, and Italy (Central Powers). After the sinking of
American merchant ships by German submarines, the United States declared war on
Germany on April 6, 1917. The Treaty of Versailles brought World War I to an end,
signed on June 28, 1919, in Versailles, France.
As noted above, Trench warfare was a novel approach to warfare. It provided
protection to the soldier for bodily injury from gunfire; however, the soldier’s face

S. R. Aziz (*)
Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine,
Newark, NJ, USA
e-mail: [email protected]
S. H. Aziz
The Wardlaw Hartridge School, Edison, NJ, USA

© The Author(s), under exclusive license to Springer Nature 71

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_6
72 S. R. Aziz and S. H. Aziz

was often exposed. In 1915, steel helmets were introduced, protecting to a degree
from brain trauma, but the face remained bare. Further, the Great War introduced a
new age of high-velocity ballistic use and injury. What resulted was a never-before-­
seen volume and severity of facial trauma—soft and hard tissue. It is estimated that
15% of all injuries were facial. Often, this injury rendered the soldier alive but with
massive tissue loss. As a consequence, this forced the evolution and laid the founda-
tions for modern-day facial reconstructive surgery. The reconstructive efforts could
be broken into two basic efforts:
1. Frontline triage and stabilization. Typically, the soldier was stabilized, facial
fractures reduced, and facial soft tissue injury treated for infection and hemor-
rhage. Soldiers were then transferred away from the front to more sophisticated
centers. The best documented frontline efforts were by the Harvard Surgical
Unit’s maxillofacial team led by Dr. Varaztad Kazanjian.
2. Tertiary care centers away from the front lines where hard and soft tissue recon-
structive surgery occurred. The best known of these were two:
(a) Sidcup—led by Sir Harold Gillies
(b) Berlin unit—led by Professor Jacques Joseph

2 Front-Line Care: Origins of the Harvard Unit

Although the US government remained officially neutral during the early years of
the Great War, the American people strongly supported the cause of the Allied
Powers. Sir William Osler proposed that leading American and Canadian universi-
ties should provide the Allied Forces with medical services near the fields of battle.
Harvard, Johns Hopkins, Columbia, and McGill Universities arranged for medical
“units” to be part of the Royal Army Medical Corps of the British Expeditionary
Forces in France. On June 26, 1915, Harvard sent to England the first of 3 surgical
units led by Dr. E. H. Nichols and composed of 32 surgeons, 3 dentists, and 75
nurses (the subsequent 2 units were led by Dr. David Cheever and Dr. Hugh Cabot,
respectively).
When the First Harvard Unit was being formed, Dr. Nichols requested that Dr.
Eugene Smith, Dean of the Harvard Dental School, select three dentists for inclu-
sion. Smith, in turn, nominated Dr. Varaztad H. Kazanjian, who was at the time
Instructor in Mechanical (Prosthetic) Dentistry and a 1905 graduate of the School,
to be the Chief Dental Officer of the Dental Department of the Harvard Unit. Dr.
Kazanjian readily accepted and chose as his assistants Ferdinand Brigham and
Frank Cushman, both graduating seniors from Harvard Dental School. Brigham in
his memoirs wrote:
Dean Smith sensed it was the most dramatic event in the history of the school, and he
intended to make the most of it. He chose Dr. Kazanjian with instinctive judgment, based
on all his experience in choosing men and shaping dental events. Dr. Smith knew his man,
knew that his quiet unassuming manner which has confounded many from that day to this
The Legacy of Maxillofacial Surgery During the Great War 73

into thinking that he was timid or unmethodical, cloaked a thoroughgoing ability to forge
ahead, an ease of organizing, and imagination in meeting the unknown . . .. I am not aware
that Dr. Smith considered any other candidate than Dr. Kazanjian. He had the interest of the
school at heart. He read the future carefully (Brigham 1964).

Varaztad Kazanjian (1879-1974) was a remarkable individual. Born in what is

now Eastern Turkey, of Armenian heritage, he immigrated at age 16 to the United
States to avoid persecution by the Ottoman Empire. Settling in Massachusetts, he
later attended Harvard Dental School, graduating in 1905, and further trained as a
prosthodontist. He then served as a faculty member at the dental school. Following
World War 1, Kazanjian then completed his medical degree at Boston University
and returned to Harvard as a Professor of Oral Surgery and the first Professor of
Plastic Surgery. He is considered to be one of the founders of modern plastic sur-
gery, though he never forgot his roots in dentistry. (Fig. 1)
The members of the Harvard Unit had a unique status in the Royal Army. Not
British subjects, they were granted temporary honorary commissions in the Royal
Army Medical Corps. The British War Office assigned this unit to Number 22
General Hospital at Dannes and Camiers, France. Dannes and Camiers were two
hamlets located 14 miles south of Boulogne-sur-mer. No. 22 was one of five base

Fig. 1 Portrait of Dr.

Kazanjian in foyer of the
Harvard School of Dental
Medicine, Boston, MA,
USA. Reproduced with
permission and without
alterations
74 S. R. Aziz and S. H. Aziz

hospitals situated in northern France. The hospital contained 1800 beds and was
equipped with surgical and medical wards and operating facilities. The professional
staff was housed in waterproof tents. These military base hospitals were adjacent to
the front lines of fighting and sent “surgical teams” (teams of surgeons, anesthesi-
ologists, and nurses) to the frontline casualty-clearing stations for emergent care,
for triage of the injured, and to facilitate a smooth transfer of the wounded to base
hospitals.
Arriving in Dannes-Camiers, France, in July 1915, the Harvard dentists were the
first to commence work. They were assigned one ward in the hospital and were kept
busy with exodontia and prosthetic dentistry. Dr. Cushman later wrote in the Harvard
Alumni Bulletin:
Upon the arrival of the Unit in France, dental conditions were found to be much worse than
expected. Until it became known throughout the district that fractures of the jaws were
being treated by the Harvard Unit, much of the work was concerned with extraction of teeth
and the making of artificial dentures. The most important phase of the work of the dental
men in the Unit was, of course, the treatment of the cases of fractures of the jaws, and
before the work was long underway, many cases of this sort were being brought in from the
front and from other hospitals. The injuries were often very extensive, involving in addition
to the jaws, other parts of the face and cranium. External wounds necessitate an entire
change of procedure from the methods used in jaw fractures in civil hospitals. Owing to the
drainage of Saliva through these wounds, the sepsis is widespread and persistent. Too much
credit cannot be given to Dr. Kazanjian for the masterly way in which these cases are being
handled (Fig. 1). Each new case requires the devising of special appliances to fit its particu-
lar needs; but this Harvard man is always found equal to every occasion (Cushman 1916).

One week after his arrival in France, Kazanjian created a plan for the Dental
Department of the First Harvard Unit which consisted of two phases: (1) routine
dental care for soldiers and (2) oral and maxillofacial surgery. When the 3-month
term of the First Harvard Unit came to an end, the British War Office, cognizant of
Kazanjian’s excellent fieldwork, requested that he stay on until the end of the war or
until he could train a successor. Kazanjian, while willing, was concerned about his
absence from his position at the dental school. Six surgeons of the unit petitioned
Harvard President Lowell to allow Kazanjian to remain. Lowell cabled an affirma-
tive response. Kazanjian then requested that the British War Office allow his assis-
tants to remain and to provide better facilities in which to work. The British agreed
and provided Kazanjian and his unit with better space and larger wards, relocating
them to General Hospital 20.
Kazanjian wrote an article in the 1917 British Medical Journal detailing the daily
activities of the Dental Department of the Harvard Surgical Unit. He noted that
“soldiers who have received wounds of the face and jaws have for the first time been
collected in centers for treatment.” Advantages of this system included a nursing
staff properly trained to efficiently handle maxillofacial injuries, the development of
a dental laboratory that quickly produced splints and appliances necessary for treat-
ment, and the opportunity to maintain a “comprehensive system of records from
which deductions can be made on the complications, mortality, etc....” Cases were
usually admitted to the dental department 2–3 days after injury. Kazanjian divided
treatment into two distinct periods: the first, or early period (usually 3–4 weeks after
The Legacy of Maxillofacial Surgery During the Great War 75

injury), which he considered essential for a successful outcome. During this time,
soldiers usually suffered from mental shock, toxic absorption from the wounds,
exhaustion secondary to blood loss, and malnutrition secondary to inflammation of
the oral cavity and damage to the masticatory apparatus. Further, it was during this
period that patients were at highest risk for serious complications such as hemor-
rhage, bronchopneumonia, and generalized sepsis. The microorganisms involved in
the septicemia were thought to be streptococcal; however, no positive identification
was completed. Cellulitis was observed, originating from the wound and spreading
over the face and scalp and accompanied by pyrexia. Bronchopneumonia was con-
sidered the most fatal complication. Some cases occurred suddenly, others gradu-
ally. Empyema and multiple abscesses in the lung were common. The pulmonary
infections seemed to originate from the inhalation of septic material from the mouth.
To prevent the onset of sepsis, initial treatment involved irrigation of the mouth at
2-hour intervals during the day and night and swabbing of the soft tissues with
iodine-soaked cotton. This was followed by surgical debridement of the wound
under local anesthesia (Kazanjian 1917).
The second period was the convalescent period. During this time, definitive treat-
ment of the oral and maxillofacial region was undertaken, including repair of the
hard tissues by means of splints, construction of prosthetic appliances, and recon-
structive operations for the repair of facial deformities. Based on his clinical experi-
ence, Kazanjian developed several basic principles for treating facial fractures:
immediate immobilization of the fracture via the use of splints, reestablishment of
the dental occlusion as a guide for fracture reduction, early wound care and cleans-
ing to minimize sepsis, and the control of blood loss. Kazanjian emphasized that
early immobilization of fractures was the quickest and best means for recovery, and
in turn, it reduced soft tissue inflammation and the risk of infection and increased
patient comfort. He noted that the primary function of splints was the fixation of
bony fragments, which in turn provided support for overlying soft tissues. Nearly
every splint was custom-made to suit each case. For cases of “ordinary” severity,
standard splints were used to immobilize the jaw. In cases of extreme destruction of
hard and soft tissues, Kazanjian found that intraoral splints were inadequate; an
external support system composed of a series of vulcanite plates fitted over the fore-
head, and a headgear, was developed. This appliance stabilized the tissues of the
mouth, nose, eyes, and neck. For extensive mandibular loss, Kazanjian created a
sectional or folding artificial jaw; it acted as a framework for reconstructive opera-
tions and maintained the contour of the lower face. If the temporomandibular joint
was involved in the injury, he placed a mechanical condyle to restore joint function.
Before the Harvard Unit’s arrival, one major flaw in the care of maxillofacial war
injuries was the basic lack of dental training on the part of the military surgeon.
Kazanjian noted that if a surgeon was called upon to treat a fracture of the mandible,
in many instances, he approximated the segments with wires or metal plates without
regard to the occlusion of the teeth, while the dentist, in attending a similar injury,
almost invariably applied intermaxillary ligation or immobilization of the jaw by
some form of splint attached to the teeth which brought the jaws and teeth into natu-
ral occlusion. The key to Kazanjian’s success was his training as a prosthodontist.
76 S. R. Aziz and S. H. Aziz

He used dental occlusion as the guide for reduction of the fracture—a principle well
known in the dental community but novel to the medical clinician. His work during
the Great War with general surgeons brought to light this basic principle of fracture
reduction in the medical community, bridging the “no-man’s-land” between medi-
cine and dentistry (Kazanjian 1920).
With regard to management of the soft tissues, Kazanjian wrote that “there does
not appear to be much scope for primary suturing of gunshot wounds complicated
by fracture of the jaw. Some advantages may follow accurate primary suture of
those portions of the wound which involve the lip margins, the eyelids, the alar of
the nose, portions of the external ears or the outlying tributaries of a radiating
wound.”5 He advocated the use of secondary suturing to lessen the amount of scar-
ring. Immediate cleansing and debridement to minimize sepsis were most important
for facial soft tissue trauma (Fig. 2). Finally, in situations in which soft tissue recon-
struction was required, Kazanjian used flap operations to cover deficiencies. He
used primary and secondary suturing to reduce the region to be covered by the flaps
and created an appliance to reproduce the bony tissue to serve as a framework to
give a natural contour to the soft tissues of the face or neck and to prevent undue
scar contraction.
During Kazanjian’s 3.5 years in Dannes-Camiers, the Harvard Unit saw 3000
maxillofacial cases (Fig. 3). News of the unit’s successful management of even the
most complex facial injury spread throughout the Allied and German medical com-
munities, and Kazanjian’s methods soon became the standard of care for the soldier
with oral and maxillofacial wounds. The British press dubbed Kazanjian the
“Miracle Man of the Western Front” in honor of his surgical accomplishments.
Kazanjian later wrote, “As I look back upon those busy years, it is apparent that the
principles and methods evolved during World War for the treatment of maxillofacial
injuries had far reaching influence on the surgical treatment of civilian injuries and

Fig. 2 Kazanjian
debriding a facial wound.
Courtesy Center for the
History of Medicine,
Francis Countway Library
of Medicine, Harvard
Medical School, Boston,
MA, USA. Reproduced
with permission and
without alterations
The Legacy of Maxillofacial Surgery During the Great War 77

Fig. 3 Patients of Kazanjian’s. Courtesy Center for the History of Medicine, Francis Countway
Library of Medicine, Harvard Medical School, Boston, MA, USA. Reproduced with permission
and without alterations

of acquired and congenital deformities of the face and jaw as well as other parts of
the body (Converse 1919).” The Harvard Unit was retired by the British Army on
January 8, 1919. Kazanjian and Hugh Cabot were both invested by King George
with the “Insignia of a Companion of the Order of St. Michael and St. George” at
Buckingham Palace (Fig. 4).

3  ertiary Care—Sir Harold Delf Gillies and the Surgeons

T
of Sidcup

As noted above, there were an unprecedented number of soldiers sustaining severe

facial injury during the Great War. Many required more than stabilization—facial
reconstructive surgery was necessary. These centers were reconstructing often
never-before-seen facial trauma. From this brutality arose novel reconstructive tech-
niques to meet the need. One of the landmark centers for facial reconstructive sur-
gery was a converted estate in the English country outside of London. Later known
as Queens Hospital and then Queen Mary’s Hospital, this center was the brainchild
78 S. R. Aziz and S. H. Aziz

Fig. 4 Immediately after receiving his investiture outside Buckingham Palace. Courtesy Center
for the History of Medicine, Francis Countway Library of Medicine, Harvard Medical School,
Boston, MA, USA. Reproduced with permission and without alterations

of a British Army otolaryngologist whose work during World War I made him a
world-famous plastic surgeon: Sir Harold Delf Gillies.
Gillies (1882–1960) was born in Dunedin, New Zealand. The son of a prominent
family that emigrated from the Isle of Bute, Scotland, he was one of eight children.
His father passed at age 4, and young Gilles then moved to Auckland. He was ini-
tially educated at Wanganui Collegiate School where he excelled as an athlete. In
1900, he was considered the premier schoolboy cricketer in all of New Zealand.
Gillies then matriculated to Gonville and Caius College, the University of
Cambridge, in 1901. During his time at Cambridge, he excelled in studies as well as
in sports. Gillies rowed for his university as well as represented England in golf. He
went on to do clinical training at St. Bartholomew’s hospital in London and trained
in otolaryngology under Sir Milson Rees (Bamji 2006).
In 1914 as the British war effort was developing, Gillies volunteered to serve as
a British Medical Officer, working with the Red Cross (Fig. 5). In January 1915, he
was sent to France where he encountered a French-American dental surgeon by the
name of Charles Valadier. Valadier had established the first British jaw surgery unit
at the 83rd base hospital in Wimereux. Ironically (and a nod to the historical issues
oral surgeons had in hospital until the 1970s), Valadier, as a dentist, required super-
vision of a physician to operate, and Gilles was obliged to be said physician. Gillies
assisted and observed the dentist Valadier treat mandibular trauma via bone grafting.
The Legacy of Maxillofacial Surgery During the Great War 79

Fig. 5 Sir Harold Delf

Gillies circa 1915 in
British Army uniform
(Meikle 2006)

Charles Valadier (1873–1931) was perhaps one of the great mystery men of
his day. French-American, he was born in Paris and educated in New York. He
claimed to be a graduate of what is now the Columbia University Vagelos College
of Physicians and Surgeons and what is now Temple University School of
Dentistry. Valadier then set up practice in New York City, though later returned
to France in 1910 to be near family. He opened a dental practice in Paris and in
1914 volunteered with the British Red Cross at the outbreak of the Great War.
Through his charming manner and patronization of his superior officers, Valadier
was able to open his own jaw unit in Wimereux (Cruse 1987). Gillies noted that
Valadier was
a great fat man with sandy hair and a florid face, who had equipped his Rolls Royce with a
dental chair, drills, and the necessary heavy metals..., with generals strapped in his chair he
convinced them of the need of a plastic and jaw unit… the credit for establishing the first
plastic and jaw unit must go to the remarkable linguistic talents of the smooth and genial Sir
Charles Valadier (Gillies and Millard 1957).
80 S. R. Aziz and S. H. Aziz

Valadier advocated principles similar to Kazanjian—debridement and irrigation of

facial injury and stabilization of the occlusion. After the war, he became a British
citizen and was knighted for his efforts. Unfortunately, he developed a severe gam-
bling problem post war and died penniless in 1931. Valadier’s work inspired Gillies
to pursue surgical reconstruction of the face. Gillies then traveled to Paris to spend
time with the French-Creole surgeon Hippolyte Morestin.
Morestin (1869–1919) was born in Martinique, the son of a doctor. He trained as
a surgeon in France. Morestin was described as a surgeon before his time—focusing
on reconstruction and the aesthetic. As such, he focused from 1914 until his death
in 1919 on the reconstruction of soldiers with devastating facial injury. He led a
surgical unit in a military hospital in Paris—Hospital Val-de Grace. It was here that
Gilles observed Morestin. Gilles later wrote:
I stood spell bound as he removed half of a face distorted with a horrible cancer and then
deftly turned a neck flap to restore not only the cheek but the side of the nose and lip in one
shot... at the time it was the most thrilling thing I had ever seen. I fell in love with the work
on the spot (Lalardrie 1972).

Morestin died prematurely in 1919 at the end of the Great War from influenza.
While many may not know his name, he was a remarkable surgeon and Gillies’s
inspiration.
After Gillies’s experience in France, he returned to England and petitioned the
British Army’s surgeon-in-chief—Arbuthnot Lane—to establish a section of the
Cambridge Military Hospital, Aldershot, dedicated to the treatment of facial injuries
in soldiers from the Front. From his French experience, Gillies valued the work of
dentists; as such, he created a multidisciplinary unit of surgeons, dental/oral sur-
geons, anesthesiologists, and others. July 1916 brought the Battle of the Somme.
Gillies’s unit was overwhelmed with facial casualties. As such, Lane directed Gillies
to establish an entire hospital, under Gillies’s direction, dedicated to the repair of
facial injury. Gillies found a vacant mansion (named Frognal) in Sidcup, Kent, and
quickly converted it into a 1000-bed hospital which was named Queen Hospital
(renamed Queen Mary’s Hospital in 1928), opening in June 1917. Gillies then
recruited surgeons from New Zealand, Canada, and Australia as well as the United
States to set up respective units within Frognal. For the next 3 years, they treated
over 5000 men. And reconstructive efforts continued from 1920 to 1929 with an
estimated 8500 men treated. Gillies separated the hospital into geographic units:
1. British Unit—led by Gillies
2. Canadian Unit—led by Fulton Risdon and Carl Waldron
3. New Zealand Unit—headed by Henry Pickerill
4. Australia Unit—Henry Newland
Sidcup is long considered the place where the foundations for modern facial
reconstructive surgery evolved, with Gillies its founder (Fig. 6). And while this is
certainly true, Sidcup was so much more. It was a place where there was a true
understanding for the need of multidisciplinary care to ensure ultimate facial recon-
struction, especially the marriage between dental surgeons and medical
The Legacy of Maxillofacial Surgery During the Great War 81

Fig. 6 Surgeons of Sidcup, June 1918 (Pickerill 1954)

“maxillofacial” surgeons. Indeed, the senior dental surgeon Kelsey Fry who worked
with Gillies is said to have told Gillies on their first meeting, “I’ll take the hard tis-
sues. You take the soft.”
Gillies also appreciated the need to document the work done—as such, he hired
photographers, painters, and others. Of note was the surgeon turned artist Henry
Tonks, who documented through drawings and painting the work done at Sidcup.
The results were astonishing. The following were developed at Sidcup:
1. The tubed pedicle flap
2. Temporalis muscle transfer flap for zygomatic defects
3. Epithelial inlay flap for reconstruction of eyelids and intraoral vestibuloplasty
4. Autogenous bone grafting to the jaws as designed by oral surgeon Kelsey Fry
5. Advances in nasal reconstruction by Henry Pickerill
6. Perhaps most importantly the nasal endotracheal tube and associated forceps
developed by Ivan Magill and Stanley Rowbotham
As noted earlier, much of what was being developed was in an attempt to primar-
ily close large avulsive facial soft tissue injury. They allowed the surgeons at Sidcup
to refine techniques of local and pedicled soft tissue flaps. Further, to reconstruct
facial hard tissue injury, Fry and others developed techniques of bone grafting from
the rib and tibia. Gillies developed a reconstructive technique known as the tubed
pedicle flap. This was a myocutaneous flap. Unfortunately for Gillies, a Ukranian
surgeon Vladimir Filatov independently also developed the same flap and published
his technique prior to Gillies. In addition, Gillies modified Esser’s epithelial inlay
82 S. R. Aziz and S. H. Aziz

flap for reconstruction of eyelid injury using pedicled oral mucosa. Finally, Fry and
Gillies designed an onlay flap for vestibuloplasties, using stents—a technique com-
monly used today.
One of the key members of Gillies multidisciplinary team was Kelsey Fry.
William Kelsey Fry (1889–1963) was educated in medicine and dentistry at Guy’s
Hospital, receiving his medical degree in 1912 and dental qualification in 1913. It is
said that Fry, while a student at Guy’s, developed a love for facial and oral surgery
after watching Sir Arbuthnot Lane repair a cleft palate on an infant. However, before
he could start training formally in oral surgery, Fry was recruited into the British
Army’s medical core. Fry was dispatched to the front lines in France and was imme-
diately wounded. He, by coincidence, convalesced at Guy’s Hospital. Fry returned
to France but was later posted to assist Gillies at Cambridge Hospital, later Sidcup.
At Sidcup, the team of Gillies Fry and Magill dealt with facial trauma never before
seen (Fig. 7). Fry utilized the methods by American field oral surgeons Kazanjian
and Henry Sage Dunning (who later founded Columbia University’s dental school)
to stabilize facial fractures by use of external fixation and splints with Gillies’s
developed methods of autogenous bone grafting to mandibular defects.
Perhaps most interesting of Fry’s achievements was working with anesthesiolo-
gist Ivan Magill and Stanley Rowbotham. Magill and Rowbotham championed the
idea of intratracheal (endotracheal) nasal anesthesia—mainly out of necessity
(Fig. 8). Prior to the Great War, anesthesia was often simply administered via mask
inhalation. However, because of the degree of facial trauma, mask inhalation was

Fig. 7 Sir William Kelsey

Fry. From national portrait
gallery website https://
www.npg.org.uk/
collections/search/portrait/
mw106643/
Sir-­William-­Kelsey-­Fry
The Legacy of Maxillofacial Surgery During the Great War 83

Fig. 8 Sketch by Henry

Tonks of Gillies, Fry, and
Magill at work in Sidcup

impossible. As such, Magill proposed using an endotracheal tube placed either

through the nose, mouth, or neck out of the field of surgery. The first tube was
designed by Magill and physically built by Fry in his dental laboratory in Sidcup.
Needless to say, eventually, this anesthetic technique revolutionized the specialty.
Fry spent his career as an academic, championed the naming and classification of
the specialty of oral surgery in the United Kingdom, and ultimately helped establish
the Faculty of Dentistry of the Royal College of Surgeons of England in 1947
(Anonymous 1966).
For all their efforts, Gillies and Fry (British citizens) received knighthoods,
becoming Sir Harold Gillies and Sir William Kelsey Fry. Gillies went on to become
known as the father of modern plastic surgery.

4 Maxillofacial Surgical Advances by the Central Powers

While the English language medical literature has detailed the exploits of Kazanjian,
Gillies, and other maxillofacial surgeons of the Allied Forces, not as much has been
written in English medical journals about the advances made by the German sur-
geons and other Central Power surgeons. However, significant and similar progress
in the treatment of maxillofacial war injuries was attained by surgeons from the
opposite side of the front line. In fact, some medical historians argue that many of
Gillies’s surgical advances were based on techniques originated by Central Power
surgeons. There were two prominent centers of maxillofacial reconstructive sur-
gery: Dusseldorf and Berlin. The prominent Central Power surgeons at these centers
were Auguste Lindemann (1880–1970) (Dusseldorf), Jacques Joseph, and Johannes
Esser in Berlin.
Lindemann was already a well-known facial surgeon prior to the Great War. In
1914, he founded the world’s first hospital dedicated to facial surgery in
84 S. R. Aziz and S. H. Aziz

Dusseldorf—the Dusseldorf Hospital for the facially injured. During the Great War,
Lindemann developed iliac crest grafting to reconstruct mandibles using wires for
stabilization. He also published this work; Gillies noted that some of his reconstruc-
tive efforts were based on reading Lindemann’s work. In 1916, Professor Jacques
Joseph (1865–1934) was appointed to the Department of Facial Plastic Surgery at
the Ear, Nose, and Throat Clinic of Charité Hospital in Berlin. Born in Prussia to a
Jewish family, early in his medical career, he developed a love for facial aesthetic
surgery, pioneering otoplasties and rhinoplasties. His soft tissue work was remark-
able, and he meticulously documented his work. Worthy of note was Joseph’s
reconstruction of a Turkish soldier who had most of his midface lost to injury. Over
the course of multiple soft tissue combined with dental prosthetic surgeries, Joseph
restored this soldier’s face (Fig. 9). After the war, Joseph focused on nasal surgery,
becoming world famous in the rhinoplasty. He suddenly died in 1934 in his home in
Berlin (Thomas et al. 2019).
Johannes Esser (1877–1946) was a Dutch reconstructive surgeon. Like Morestin,
his landmark work in facial reconstruction is often overlooked. As a young man,
Esser became the Dutch chess champion in 1903. He enrolled in medical school at
the University of Leiden; his sister also attended the university’s dental school. Esser
managed to accompany his sister to her dental courses and thus trained simultane-
ously in medicine and dentistry. Following graduation, he became a country doctor
but quickly found that his passion was in surgery of the face. Esser then went to Paris
to study under French surgeons, including Morestin. At the start of the Great War,
Esser offered his expertise to both the French and the British; neither accepted as he

Fig. 9 Turkish lieutenant Mustafa Ipar, Joseph, Jacques. Nasenplastik und sonstige Gesichtsplastik:
Nebst einem Anhang über Mammaplastik und einige weitere Operationen aus dem Gebiete der
äußeren Körperplastik. Leipzig: Curt Kabitzsch, 1928–1931
The Legacy of Maxillofacial Surgery During the Great War 85

was a Dutch citizen. He returned to Holland and began a facial plastic surgical prac-
tice. Esser then offered his services to the Austrian-Hungarian government, who
accepted. He was posted to a hospital in the Czech Republic, where his surgical
skills in facial flap surgery gained him notoriety. Esser later worked at the University
of Vienna, and at the end of the war, he was given a 150-bed ward in Berlin to treat
injured soldiers. From his war experience, Esser published his experience and gained
significant celebrity in the European surgical community. One of his flaps, the epi-
thelial inlay flap, was used frequently by Gillies, who called it the “Esser outlay.” As
World War II approached, he again offered his services to France but was once more
turned down. Frustrated, Esser and his son decided to travel to the United States,
hoping to establish a center for facial plastic surgery. Esser never was able to estab-
lish this center, though he did find a place in the medical community in Chicago to
lecture (he was not allowed to practice medicine in the United States due to licensing
restriction). Esser passed away at age 69 at his home in Chicago (Tolhurst 2015).

5 Anna Ladd and Jane Poupelet and Their Facial Masks

A synopsis of facial surgery during the Great War would not be complete without
mention of two women who in their own nonsurgical way reconstructed the disfig-
ured faces of soldiers from the front line: Anna Coleman Ladd and Jane Poupelet.
Anna Ladd was born on July 15, 1878, in Bryn Mawr, Pennsylvania. She was born
into a wealthy American family and grew up in Paris, France, until the age of 21. In
1900, Ladd moved to Rome to proceed in studies focused on art and sculpting. She
married Maynard Ladd, a pediatric gastroenterologist.
Anna Ladd was introduced to the face masks by Lewis Hine, an English art
critic. While visiting Ladd in Boston, Hine gave her an article written by British
sculptor Derwent Wood. In the article, Wood explains the creation of the face masks
used on soldiers who suffered from war-related disfigured faces. Due to the serious-
ness of the permanent facial injuries, many soldiers felt socially embarrassed—
some even wished to die rather than face this agony. These masks allowed soldiers
to return to a relatively normal life.
In 1917, Maynard Ladd went to France to work for the children’s section of the
American Red Cross. Anna Ladd of course followed him to Paris. She petitioned the
American Red Cross to create a division that specialized in creating face masks.
This would later become known as the Studio for Portrait Masks for Mutilated
Soldiers in Paris in 1917. Ladd hired the French artist Jane Poupelet (1874–1932) as
her assistant. Poupelet was born in 1874 in Dordogne, France. Prior to the war, she
developed her skills in Paris. Due to the cultural and social limitations of nineteenth-­
century France which restricted the work of female artists, Poupelet often exhibited
her work (usually female nude and farm animal sculptures) under the male pseud-
onym Simon de la Vergne. A patriotic French woman, she wanted to aid the injured
French soldier; her meeting with Anna Coleman Ladd became the opportunity she
desired.
86 S. R. Aziz and S. H. Aziz

Fig. 10 Anna Coleman

Ladd fitting a mask on a
soldier with a mutilated
face. (Library of
Congress - https://www.
loc.gov/pictures/resource/
cph.3c37180/)

From 1917 to 1920, these women created 250 masks for soldiers. The process
required several steps:
1. Moulage of disfigured soldiers’ face
2. Modelling of the missing parts of the face based on pre-injury photography
3. Manufacturing a cooper prosthesis
4. Adjusting the prosthesis to the face
5. Painting the mask to appear human
Following the war, Ladd returned to Boston where she received much publicity
for her work for the American Red Cross. Her masks would create new “trends”
in this century by incorporating a new aspect of modernism into art and making
an impact on looks in pop culture at this time. Poupelet remained in France but
stopped sculpting, focusing on sketch art. Years later, they were both awarded the
title of Knight of the French Legion of Honor (Room and Zacher 1982; Benmoussa
et al. 2020; https://www.dailyartmagazine.com/jane-­poupelet-­bronze-­paper-­and-­
commitment-­in-­wwi/). Ladd passed away in 1939 and Poupelet in 1932 (Fig. 10).

6 Summary

Trench warfare combined with advances in ballistics created a never-before-seen

number of mutilated faces requiring repair during the Great War. Ironically, horrific
human conflict often leads to advances in medicine, dentistry, and surgery as a
required response. The work of these surgeons made them legends as well as laid
the foundation for what we as maxillofacial surgeons do today. What perhaps is
most amazing is how these surgeons handled catastrophic trauma in the pre-­
antibiotic era.
The Legacy of Maxillofacial Surgery During the Great War 87

References

Anonymous. Great teachers of surgery in the past. Sir William Kelsey Fry (1889-1963). Br J Surg.
1966;53(4):317–20.
Aziz SR. Harvard dental school and the fight for the ideals of democracy. J Oral Maxillofac Surg.
2001;59:428–33.
Bamji A. Sir Harold Gillies: Surgical Pioneer. Trauma. 2006;8:143–56.
Benmoussa N, Fanous A, Charlier P. Jane Poupelet: a woman artist devoted to the wounded sol-
diers from the First World War. J Stomatol Oral Maxillofac Surg. 2020;121:323–6.
Brigham F. Harvard goes to war. Harvard Dental Alumni Bull. 1964;24:100.
Converse JM. The extraordinary career of Dr Kazanjian. Plast Reconstr Surg. 1919;71:138.
Cruse WP. Auguste Charles Valadier: a Pioneer in maxillofacial surgery. Mil Med. 1987;152:7:37.
Cushman F. Work of Harvard Dental School graduates in France. Harvard Alumni Bull.
1916;28:614.
Gillies HD, Millard RD. The principles and art of plastic surgery. Boston: Little Brown; 1957.
p. 6–15.
https://www.dailyartmagazine.com/jane-­poupelet-­bronze-­paper-­and-­commitment-­in-­wwi/.
Kazanjian VH. The Department of Oral Surgery of the Harvard Surgical Unit. Br Med J. 1917;154:3.
Kazanjian VH. Observations on war surgery of the face and jaws. Dental Cosmos. 1920;62:283.
Lalardrie JP. Hippolyte Morestin 1869-1918. Br J Plast Surg. 1972;25:39–41.
Meikle MC. The evolution of plastic and maxillofacial surgery in the twentieth century: The
Dunedin Connection. Surgeon. 2006;4:325–34.
Pickerill HP. The Queen’s Hospital, Sidcup. Br J Plast Surg. 1954;6(4):247–9.
Room S, Zacher J. Anna Coleman Ladd: maker of masks for the facially mutilated. Plas Reconst
Surg. 1982;70(1):104–11.
Thomas RL, Fries A, Hodgkinson D. Plastic surgery pioneers of the central powers in the great
war. Craniomaxillofac Trauma Reconstr. 2019;12:1–7.
Tolhurst D. Pioneers in plastic surgery. Cham: Springer; 2015. p. 55–62.
Formation of Head and Neck Surgical
Specialties

Gabriel M. Hayek and Michael T. Goupil

1 Introduction

The practice of surgery has a long history. The first known surgery dates back to
10,000 BCE, the New Stone Age. Skulls discovered in France in 1695 showed evi-
dence of trephination. Considered to be the oldest surgical text, and perhaps the first
book, is the Edwin Smith Papyrus (Fig. 1). These Egyptian writings date back to
1600 BCE and are believed to contain material older than that.
The first replacement of a nose, rhinoplasty, is described in the Hindu literature
of the fifth century and may be considered to be the origin of otorhinolaryngology.
Plastic surgery may trace its origins back to the Tsin dynasty (~266–470 BCE where
a Chinese plastic surgeon treated harelip, sometimes known as cleft lip). The sur-
geons trained by Hippocrates were believed to treat disorders of the eyes, ears, nose,
throat, and teeth. In addition, Hippocrates described immobilization methods for the
treatment of jaw fractures (Bishop 1995).
The specialization in medicine can be traced back to the ancient Greek period. In
500 BCE, the Greek historian Herodotus described the specialization of Egyptian
medicine: “Each physician limits himself to one area of disease. Some specialize in
eyes, others in the head, teeth, the abdomen and its parts…” (Hoffman-­
Axthelm 1981).
Initially, head and neck surgical specialization was based on the interest and
expertise of the surgeon in a regional anatomical area. Over time, specialties within
these regional anatomical areas evolved, but with advances in medicine and resident

G. M. Hayek
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
Consultant in Oral and Maxillofacial Surgery, Carmel, IN, USA

© The Author(s), under exclusive license to Springer Nature 89

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_7
90 G. M. Hayek and M. T. Goupil

Fig. 1 Page from Edwin

Smith surgical papyrus.
Wellcome Library,
London. (https://
creativecommons.org/
licenses/by/4.0/)

education, the lines of demarcation for these regional areas have blurred. This chap-
ter will attempt to describe the evolution of the four primary surgical specialties of
the facial region – otolaryngology (head and neck surgery), ophthalmology, oral and
maxillofacial surgery, and plastics and reconstructive surgery.

2 Otolaryngology and Head and Neck Surgery

2.1 Birth of the Specialty

The terms otolaryngology, otorhinolaryngology, and ear, nose, and throat (ENT)
surgery are the same specialty. The term used depends on geography and the target
audience. The specialty developed in the early twentieth century when the separate
fields of otology and laryngology were united (Weir 2000). Initially, otology was
practiced by surgeons, whereas laryngology was practiced medically by clinicians.
One of the earliest physicians, the Egyptian Sekhet (~3500 BCE), appears to be
the first rhinologist: “he cured the king’s nostrils” (Helidonois 1993). The Edwin
Smith Papyrus dating to 1600 BCE describes clinical surgery including trauma to
the head and facial structures (Helidonois 1993). Similarly, the Eber’s papyrus
(~1500 BCE) contains a chapter on the hard of hearing including tinnitus and dizzi-
ness (Nogueira et al. 2007). The greatest in the Hindu literature for the specialty was
the reconstruction of a new nose using cheek and forehead soft tissue flaps in the
sixth century BC by Sushruta (Helidonois 1993).
Formation of Head and Neck Surgical Specialties 91

Fig. 2 Celsus, Aulus

Cornelius, author (US
National Library of
Medicine, public domain)

The Byzantine Compiler, Paul of Aegina, among other things described the
removal of tonsils using a hook and scalpel circa around 476 BCE (Helidonois
1993), though Celsus (Fig. 2), in the first century, was the first to describe a tonsil-
lectomy using his fingers (Nogueira et al. 2007). Additionally, Celsus is often
described as the first head and neck surgeon to describe the treatment of lip cancer
with surgery, although this may have only been the treatment of a lacerated lip
(Cantrell and Goldstein 1999).
The French surgeon Guy de Chauliac (1300–1367) contributed to the field of
otology by creating the ear speculum to introduce “sunlight onto the external audi-
tory meatus” to remove foreign bodies. He also treated quinsy by using an incision
for drainage (Helidonois 1993). The father of modern otology was the physician
Adam Politzer (1835–1920) who taught in Vienna. One of his students, Robert
Barney (1876–1936), was the Nobel Prize winner for his work on the vestibular
organ (Helidonois 1993).
The origins of laryngology are attributed to Manuel Garcia (1805–1906), a sing-
ing teacher who was able to view his own larynx with a mirror. More likely, this
92 G. M. Hayek and M. T. Goupil

aspect of the specialty should be credited to Benjamin Babbington, a London physi-

cian who performed the first laryngoscopy using his “glottiscope” in 1829 (Weir
2000). One of the first larynx procedures is attributed to Alexander the Great
(356–323 BCE). He saved the life of one of his soldiers by using the point of his
spear to perform the first cricothyrotomy (Nogueira et al. 2007).
Significant advancements in the specialty of otolaryngology have been made
throughout history by physicians, surgeons, and anatomists. This is one of the first
specialties to perform procedures using local anesthesia and the first to perform
surgery with microscopes and endoscopes (Nogueira et al. 2007).

2.2 Organizations

Medical history demonstrates that physicians that have a similar interest in a par-
ticular area form an association to share knowledge. With the development of the
otoscope and the laryngoscope in the late 1850s, a number of physicians became
interested in treating diseases of the ear, nose, and throat. This led to the formation
of the American Otological Society in 1869 and the American Laryngological
Association in 1879 (Cantrell and Goldstein 1999).
In 1896, Dr. Hal Foster, an otolaryngologist, invited colleagues to the first meet-
ing of the Western Association of Ophthalmologists, Otologists, and Laryngologists.
Noting that members were coming from all over the country, this organization
became the American Academy of Ophthalmology and Otolaryngology (AAOO) in
1903. Four years later, with 434 members, it became the largest medical specialty
society in America. As the academy grew larger, it became difficult to find a venue
to hold the national meeting. This eventually led to a separation of the AAOO in
1979, forming two separate groups – the American Academy of Otolaryngology
and the American Academy of Ophthalmology (www.aao-­hns).
The name extension of head and neck was added to otolaryngology in 1978 to
better define the changing scope of the specialty (Jackler and Mundry 2013). The
American Academy of Otolaryngology-Head and Neck Surgery is now the largest
organization in the world of specialists that treat the ear, nose, throat, and related
structures (www.aao-­hns).
A similar organization of ophthalmologists and otolaryngologists formed a sec-
tion within the American Osteopathic Association. This became an independent
organization in 1918 forming the American Osteopathic Society of Ophthalmology
and Otolaryngology. This organization disbanded in 1944 and formed a coalition
with the international society and is known as the Osteopathic College of
Ophthalmology and Otorhinolaryngology. Like the AAO-HNS, the extension of
head and neck surgery was added in 1995. They are now known as the American
Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck
Surgery (www.aocoohns.org). The main function of these organizations continues
to be education, research, and adherence to high standards.
Formation of Head and Neck Surgical Specialties 93

3 Ophthalmology

3.1 Birth of the Specialty

Similar to other specialties, ophthalmology has a long history dating back thou-
sands of years. The earliest written records make note of the magical importance of
the eye. This reference to the “evil eye” continues to the present day (Arrington and
Marti-Ibanez 1959, p. 11). The earliest record of ocular therapeutics, including legal
ramifications, “an eye for an eye,” is found in the Code of Hammurabi (circa 1900
BCE) (Arrington and Marti-Ibanez 1959, p. 12, 13; Wheeler 1946).
The Indian surgeon Sushruta (800 BCE) predates Hippocrates and was consid-
ered the “father of Indian medicine.” He dealt extensively with ocular anatomy and
physiology. He described 76 ocular diseases. Many of his treatments were surgical
in nature, and he is also considered to be the “father of cataract surgery” (Arrington
and Marti-Ibanez 1959, p. 13, 14; Smith 2019). Herophilus (335 BC–280 BCE), a
Greek physician, coined the term retina and gave the first description of the anatomy
of the eye (Arrington and Marti-Ibanez 1959, p. 32).
Roger Bacon is credited with the use of lenses to assist old people with weak
eyesight. In 1268, Bacon wrote on optics in general and specifically the use of
lenses in his Opus Magnus. His lenses were used by placing them on the text to be
read rather than worn as glasses (Wheeler 1946).
Georg Bartisch (1535–1607), a German physician considered to be the Father of
Ophthalmology, started his medical education apprenticed to a barber-surgeon. He
is given this title because he wrote the first textbook totally devoted to ophthalmol-
ogy in 1583, Ophthalmodouleia das ist Augendienss, and he was the first surgeon to
purposely remove an eye from a living patient. Bartisch gave the specialty its name.
Bartisch’s textbook was quickly followed by the first ophthalmology textbook in
English, Briefe Treatise Touching the Preservation of Eye Sight, published by Walter
Baily in 1584 (Arrington and Marti-Ibanez 1959, p. 84).
In 1803, the first formal course in ophthalmology was taught at the University of
Göttingen (Tikkanen 2019). Following this in 1805, the Moorfield Eye Hospital was
founded in London. This was the first institution dedicated to the practice and teach-
ing of ophthalmology. It is home to the Institute of Ophthalmology, making it the
largest eye hospital in the world (Smith 2019).
In 1851, Hermann Helmholtz published his paper describing his invention, the
ophthalmoscope, making the clinical practice of ophthalmology a more exact sci-
ence. The English physician Charles Babbage may actually have invented this
device earlier, but unfortunately, he did not publish his work (Wheeler 1946).
94 G. M. Hayek and M. T. Goupil

3.2 Organizations

The professional organization of ophthalmology as noted above was started by the

1890s by the Kansas City ophthalmologist Hal Foster. Through his leadership, the
American Academy of Ophthalmology and Otolaryngology (AAOO) was estab-
lished in 1903. Due to size and logistical issues, the organization separated into two
groups in 1979. The American Academy of Ophthalmology moved its headquarters
to San Francisco. This academy is now the largest association of physician and sur-
geons dedicated to the treatment of the eye.
The American Board of Ophthalmic Examinations was formed in 1916 and,
upon incorporation the following year, became the first medical specialty-certifying
board in the United States (Cantrell and Goldstein 1999).

4 Oral and Maxillofacial Surgery

4.1 Birth of the Specialty

The earliest recorded history of what is now in the scope of oral and maxillofacial
surgery dates to 2700 BCE Egypt, in which the Edwin Smith Papyrus details 48
cases treated by military surgeons (Laskin 2016; Tiwari et al. 2017). Among these
include the treatment of mandible fractures with bandages soaked in honey and egg
white, closing wounds with sutures, and the repair of broken noses. The written
treatment of oral disease dates to 1200 BCE in ancient Greece. The treatments were
administered in temples by priests called asclepiads who were followers of
Asclepius, the Greek God of Medicine. Although these were largely herbal reme-
dies, there is also evidence of tooth extraction.
In the fourth century BCE, Hippocrates (460–270 BCE) and Aristotle (384–322
BCE) wrote about tooth extractions (of loose teeth only) by applying substances to
degrade the periodontal ligament, removing the crown, or cauterizing the pulp to
stop pain, incision and drainage of abscesses, manual reduction of temporoman-
dibular joint dislocation, and using wires across teeth to support mandible fractures.
After the fall of the Greek and Roman empires, the age of Islamic medicine
would usher in the teachings of Rhazes (854–932), Albucasis (936–1013), and
Avicenna (980–1037), who would detail more involving surgical procedures includ-
ing the excision of oral fistulae, ranulas, epuli, frenula, thyroidectomies, and tempo-
ral artery division for the treatment of some headaches. They even recommended
making incisions in the lines of skin creases, centuries before Langer would for-
mally describe the principles of skin tension lines in 1861. Rhazes described remov-
ing teeth by loosening them with arsenic paste or the juice of boiled frogs.
The middle ages saw the separation of physicians, who formally studied medi-
cine at universities, and surgeons, who continued to learn their trade by apprentice-
ship, until 1540 when the British Parliament reunited the two disciplines. The
Formation of Head and Neck Surgical Specialties 95

Renaissance period would see the addition of more advanced tumor excision tech-
niques and even gunshot wounds to the literature. Ambroise Paré (1510–1590), the
Father of Surgery, treated broken jaws, excised tumors, discovered ligature to con-
trol bleeding, and improved the management of gunshot wounds by applying a mix-
ture of egg yolk, rose water, and turpentine to the wounds, as opposed to removing
bullets at all costs.
Pierre Fauchard (1678–1761), the Father of Modern Dentistry, published The
Surgeon Dentist in 1728, a comprehensive text detailing the basic anatomy of the
oral cavity and dental procedures including minor oral surgeries. Anselme Jourdain
(1731–1816) would follow in 1778 with the first known oral surgery textbook, A
Treatise on the Diseases and Surgical Operations of the Mouth and Parts Adjacent.
The name of the specialty is largely credited to James Garretson (1828–1895),
whose 1869 book, A Treatise on the Disease and Surgery of the Mouth, Jaws, and
Associated Parts, defined the scope of oral and maxillofacial surgery (Fig. 3). At
this time, Garretson recommended that oral surgery be practiced by those with a
medical degree only and suggested the removal of the DDS degree altogether. Most
oral surgeons of the time had both degrees, though many of the biggest names –
including Matthew Cryer (1840–1921), Truman Brophy (1848–1931), Thomas
Gilmer (1848–1931), and Chalmers Lyons (1874–1935) – would align themselves
with dental schools and strongly believed that oral surgery belonged to dentistry.

Fig. 3 Dr. James Edmund

Garretson, before 1895
(History of Dental Surgery,
volume 3, p. 396, public
domain)
96 G. M. Hayek and M. T. Goupil

It was not until 1994 at the American Association of Oral and Maxillofacial
Surgeons (AAOMS) House of Delegates meeting that the national association unan-
imously voted that oral and maxillofacial surgery would always remain a specialty
of dentistry, and in 1997, the American Dental Association opted for a new defini-
tion of dentistry that included the full scope of the specialty (Lew 2013).
The founding of modern oral and maxillofacial surgery in North America dates
to the mid-nineteenth century with the realization that deformities of the mouth and
face were undertreated by the medical profession. Simon Hullihen (1810–1857), a
physician with dental training from Wheeling, West Virginia, was the first to limit
his professional endeavors to the face and mouth region. He would later become the
first person to perform a successful mandibular osteotomy, foreshadowing the future
of the field. In fact, in the last 10 years of his life, Hullihen performed 100 cleft lip
and 50 cleft palate repairs, treated 100 tumors, did 200 procedures for maxillary
sinus disease, and performed 85 reconstructions of the lips, nose, and mandible, a
remarkable feat considering neither local nor general anesthesia yet existed.
Shortly thereafter, James Garretson would pioneer academic oral and maxillofa-
cial surgery, introducing oral surgery as a core component of dental education at the
Philadelphia Dental College, now Temple University School of Dentistry. He would
become the first professor of oral surgery in the nation.
While the specialty of oral and maxillofacial surgery was being founded, America
was finding itself drawn into World War I, and the two would be inextricably linked.
As there was no dental corps at the time, dental officers worked closely with medi-
cal officers, treating war-ravaged facial injuries and using their dental backgrounds
to help establish early principles of fracture stabilization and reconstruction with
techniques for obturation, intermaxillary fixation, and prosthetic rehabilitation
(Strother 2003). These techniques allowed an amazing two-thirds of wounded sol-
diers to return to the battlefield. These officers included prominent surgeons and
founders of the modern specialty such as Robert Ivy (1881–1974), Carl Waldron
(1887–1977), and Sir Kelsey Fry (1889–1963), a pioneer of British oral surgery
(Lew 2013).
Before World War I, there were no formal training programs for the treatment of
maxillofacial injuries; soldiers with extensive injuries often wore masks to hide
their deformities (Strother 2003). The surgeon general appointed Vilray Blair
(1871–1955), a general surgeon with extensive head and neck experience from
Washington University in St. Louis, as the senior consultant for maxillofacial sur-
gery. Blair named Robert Ivy, an oral surgeon from Philadelphia, as his assistant.
World War I was dominated by trench warfare, resulting in an extraordinarily high
percentage of wounds on the head and neck. Hospital units of “Plastic and Oral
Surgery” were headed each by a team of one general surgeon and one dentist, after
an intensive training course in reconstructive techniques based on the experiences of
French and British surgeons including New Zealand–born Sir Harold Gillies
(1882–1960) of Kent, Hippolyte Morestin (1869–1919) of Paris, and Auguste
Valadier of Boulogne. These European surgeons had extensive experience in maxil-
lofacial reconstruction already, as the United States entered the war much later.
These specialized maxillofacial units had much better outcomes as they stressed
Formation of Head and Neck Surgical Specialties 97

immediate stabilization, early restoration of tissues and occlusion, and limited

debridement. These principles of trauma would serve the specialty well in the
future, as the rise of the automobile would see traumatic facial injuries become a
common occurrence at home. In many regards, advancements in facial trauma con-
tinue to define the specialty today.
American oral surgery had proved its worth clinically; however, standardized
formal residency training remained at large for many decades. Most residencies
were 1-year clinical training programs served by part-time instructors (Lew 2013).
In 1956, the 3-year training program began, in which an initial academic year was
followed by 2 years of clinical training. Many of these programs, however, remained
fragmented with training needing to be completed at multiple institutions. The
3-year integrated training program became standard in 1972. In 1988, the 4-year
curriculum was implemented, which included a mandatory minimum of 12 months
of core medical-surgical training designed to close the gaps between dental and
medical education. Meanwhile, in Europe, the specialty often required a dual medi-
cal and dental background. Although a few modern oral surgeons had independently
attended medical school, Walter Guralnick (1916–2017) of the Harvard/
Massachusetts General Hospital program developed the dual-degree integrated resi-
dency training program in 1971 (Kaban and Perrott 2020). This included formal
general surgery training, further bringing the specialty into mainstream medicine.
Today, the dual-degree programs account for just under half of graduating residents.
Nevertheless, controversy remains as evidenced by a review of editorials in the
Journal of Oral and Maxillofacial Surgery (JOMS), and many have feared a schism
in the specialty akin to many European countries who had already split into oral
surgery and maxillofacial surgery (Lew 2013).
Surgeons in Germany and Austria were developing the field of corrective jaw
surgery, later to be coined “orthognathic surgery.” Previously, mandibular osteoto-
mies had been described primarily for the treatment of mandibular prognathism or
with transcervical approaches (Lew 2013; Bell 2018). Modern orthognathic argu-
ably began with Hugo Obwegeser (1920–2017), the Father of European Maxillofacial
Surgery, who published his intraoral bilateral sagittal split osteotomy technique in
1955 and later, in 1960, the modern LeFort I down fracture, ushering a new era of
major maxillofacial surgery. In 1966, Obwegeser demonstrated his groundbreaking
surgeries to a crowd of hundreds in Washington, DC. While European oral and
maxillofacial surgeons were already performing dentofacial deformity correction
and tumor surgery, Obwegeser would awaken the American specialty at a time
when many were questioning the value of the specialty given the competition
between competing specialties and a declining need for dentoalveolar surgical
services.
In 1975, William Bell (1927–2016) published his landmark study on the vascu-
larity of the maxilla, thereby demonstrating the biologic basis of orthognathic sur-
gery. Landmark advances to treatment planning were made by Timothy Turvey and
orthodontist William Proffit at the University of North Carolina at Chapel Hill, as
they defined rationale and outcomes for orthognathic surgery in the 1990s. The
2000s and 2010s would see the development of virtual surgical planning, custom
98 G. M. Hayek and M. T. Goupil

plates, and navigation, allowing for more precise and accurate outcomes to these
complex operations (see chapter Orthognathic Surgery).
Surgery of the temporomandibular joint was long performed primarily to man-
age patients with ankylosis and to reconstruct mandibular form and function after
ablative tumor surgery, trauma, or degenerative arthritic disease. Bruce MacIntosh
of Detroit, Michigan, and Leonard Kaban of Boston, Massachusetts, had developed
and clinically proven the reconstruction algorithms for costochondral rib grafts
(Lew 2013). In 1963, Christenson introduced the Vitallium fossa-eminence prosthe-
sis, and this was further improved with stock TMJ replacement devices developed
by Louis Mercuri and Peter Quinn. As with many other aspects of modern surgery,
computer planning now allows for custom temporomandibular joint replacements.
Nonetheless, temporomandibular joint surgery developed a poor reputation with
few practical uses for long-term success. The 1980s and 1990s saw the development
of arthrocentesis and arthroscopy, resulting not only in minimally invasive surgical
options but a much-improved understanding of articular diseases and refinement in
the role of surgery.
In 1982, one of the single most influential conferences in the history of dentistry
took place in Toronto, Canada. This Conference on Osseointegration in Clinical
Dentistry, led by Professor Per-Ingvar Brånemark (1929–2014), would introduce
modern dental implantology to North America (see chapter Dental Implants and
Bone Augmentation) (Lew 2013; Block 2018). Implants were initially used for
edentulous jaws but, by 1991, were being used for single tooth replacement. The
field of dental implantology, however, had its origins dating back much further than
this. There is evidence of implants to replace teeth as far back as Ancient Egyptian
and South American civilizations. In 1938, the first long-term endosseous implant
was placed by Dr. Alvin Strock (1911–1996), still in place when the patient died in
1955. Numerous iterations of the dental implant – including subperiosteal, blade
endosseous, and transosteal subtypes – would follow before Brånemark’s revolu-
tionary osseointegrated titanium implant. Brånemark would begin training perio-
dontists in the late 1980s. Before this, only oral and maxillofacial surgeons were
allowed into his training courses. Implant treatment has exploded since this time
with enormous technological advancements in hard and soft tissue grafting for site
development, implant design, and preoperative planning.
In 1986, AAOMS sponsored a landmark conference on expanding the scope of
the specialty, necessitated by the blurring of the lines of the dental specialties (Lew
2013). The potential for dental implantology to be the boon the specialty was look-
ing for had not yet been recognized. Recommendations included enhancement in
training for resident oral and maxillofacial surgeons in three distinct areas: tumor
and reconstructive surgery, cleft and craniofacial surgery, and facial esthetic sur-
gery. This has largely been met with mixed results over the last 30 years, with these
disciplines being unevenly taught and performed among residency training pro-
grams and the constant legal battle to perform the full scope of the specialty being
fought by organized medicine.
Among the earliest pioneers in expanded scope surgery were the tumor and
reconstructive surgery fellowships with Robert Marx at Jackson Memorial Hospital,
Formation of Head and Neck Surgical Specialties 99

the University of Michigan led by Joseph Hellman, the University of Maryland with
Robert Ord, and Legacy Emanuel Hospital in Portland, Oregon, with Dr. Bryce
Potter and Eric Dierks who were dual-trained in otolaryngology (Carlson 2018).
Surgeons such as R. V. Walker (1924–2011), Timothy Turvey, Douglas Sinn, Roger
West, and Larry Wolford had pioneered craniofacial surgery within the specialty
(Ricalde and Turvey 2018). Joseph Murray (1919–2012), a plastic surgeon at Boston
Children’s Hospital considered the Father of American Craniofacial Surgery, saw
the need to bridge medical and dental education to achieve the full benefits of cra-
niofacial surgery. He recruited Leonard Kaban in 1975, who is believed to be the
first oral and maxillofacial surgeon to exclusively work for a children’s hospital.
Murray would also have a significant influence on Jeffrey Posnick, a dual-trained
oral and maxillofacial and plastic and reconstructive surgeon who would develop
the first full-scope craniofacial fellowship for oral and maxillofacial surgery gradu-
ates. Nonetheless, cleft lip and palate procedures have not enjoyed the same success
as oncologic procedures, largely attributed to the efforts from plastic and recon-
structive surgeons, who head the vast majority of the approximately 200 cleft repair
teams in the United States.
Despite the difficulties, numerous fellowships have developed, which are thriv-
ing and giving new hope to what the future may hold. By 2020, there were at least
15 oncologic and reconstructive surgery fellowships and nine cleft and craniofacial
surgery fellowships formally available to graduating oral and maxillofacial surgery
residents (Lew 2013). The year 2011 would see the development of a formal section
of oral and maxillofacial surgery within the American College of Surgeons, further
recognizing the specialty’s key role within the healthcare system. In 2020, the first
AAOMS conference entirely dedicated to oral/head and neck oncologic and micro-
vascular reconstructive surgery was held. By 2020, the American Board of Oral and
Maxillofacial Surgery (ABOMS) was offering certificates of qualifications (CAQs)
to its qualified members in these two disciplines. Cosmetic surgery of the face has
also enjoyed success within the field, with over 700 AAOMS members now per-
forming facial esthetic surgeries in their practices.

4.2 Organizations

The first formal residency training programs were developed at Cincinnati General
Hospital in 1907 and the University of Michigan beginning in 1917. It wasn’t until
1947 that the first accredited residency program in oral and maxillofacial surgery
was recognized at the Pittsburgh Veterans Administration Hospital.
Dentistry’s only surgical specialty would solidify its standing in 1918 with the
founding of the American Association of Exodontists, when Menifee Howard
(1882–1958) contacted other exodontists about the need to formally organize. At
the time, its membership consisted of only 29 members (Lew 2013). One year later
in 1919, the National Dental Association, now the American Dental Association
(ADA), would formally recognize the specialty. In 1921, the name changed to the
100 G. M. Hayek and M. T. Goupil

American Society of Oral Surgeons and Exodontists (ASOSE), further differentiat-

ing themselves from dentists without formal specialization and more accurately
reflecting the interests of the membership. In 1946, the specialty would again change
its name to the American Society of Oral Surgeons (ASOS), before adopting the
current nomenclature, the American Association of Oral and Maxillofacial Surgeons
(AAOMS), in 1978.

5 Plastic and Reconstructive Surgery

5.1 Birth of the Specialty

The early history of plastic and reconstructive surgery as it applies to the head and
neck is largely the same as oral and maxillofacial surgery. The Edwin Smith Papyrus
discusses the treatment of nasal fractures via simple nasal manipulation and stabili-
zation, closing wounds with sutures, and using raw meat to stop bleeding (Laskin
2016; Tiwari et al. 2017; Goldweyn 2008; Lawrence 2016; Singh et al. 2015;
Whitaker et al. 2007). The first reconstructive surgery described dates to 600 BCE
India when Sushruta described nasal reconstruction from pedicled forehead tissue.
Gaspare Tagliacozzi (1545–1599) in 1597 Italy described nasal reconstruction with
tissue from the forearm akin to later described tube flaps. His 1597 text On the
Surgical Restoration of Defects by Grafting is considered the first plastic sur-
gery book.
The historical association between oral and plastic surgery is significant. The
impact of war paradoxically led to both the separation and development of the two
specialties while also acting as a catalyst for cooperation and progress (Whitaker
et al. 2007). After the war, surgeons focusing on post-traumatic reconstruction made
their work by refining and progressing on previously never-seen-before techniques
(Strother 2003). Among these included Armenian-American Varaztad Kazanjian
(1879–1974) and New Zealand-born otolaryngologist Sir Harold Gillies
(1882–1960), each with significant claim to the title of the Father of Modern Plastic
Surgery, as well as Vilray Blair. Gillies would lay the groundwork for many cranio-
facial reconstructive techniques and made revolutionary discoveries in skin grafting
(see chapter Surgical Flaps).
Treatment of cleft lip and palate has long been an interest in plastic and recon-
structive surgery. For most of recorded history, children with congenital deformities
were considered to be affected by evil spirits and often ignored or killed (Bill et al.
2006; Bhattacharya et al. 2009). The first known cleft repair was not performed until
the fourth century in China on future governor-general Wei Yang-Chi. From the
early fourteenth to the nineteenth century, the surgical procedure went largely
unchanged, performed in cheilorrhaphy fashion, as described by Flemish surgeon
Jean Yperman, with a looped suture called the sutura circumvoluta. Repair tech-
niques finally made an advancement in 1844 when they transitioned to a
Formation of Head and Neck Surgical Specialties 101

cheiloplasty, as described by Joseph-François Malgaigne (1806–1865) and

Germanicus Mirault (1796–1870). The modern principle of a geometric cutting pro-
cedure was first described by Werner Hagedorn (1831–1894) in 1884. This tech-
nique would be further refined by Veau (1938), LeMesurier (1949), Tennison
(1952), Millard (1958), Randall (1959), and Pfeifer (1970). The first documented
surgical treatment of cleft palate, meanwhile, was not until 1817, as documented by
Karl Ferdinand Graefe (1787–1840). The modern concept of a morphological lay-
ered closure was first brought forth by Bernhard von Langenbeck (1810–1887) in
1861 and advanced by Victor Veau (1871–1949) in 1931.
Bone grafting was first described in the early 1600s by Dutch surgeon Job Van
Meekeren (1611–1666), who attempted a cranioplasty with bone from a dog
(Ricalde and Turvey 2018). The first autogenous bone graft was performed in 1821.
Bone graft science began to develop with the description of creeping substitution by
Barth in 1893 and a case series on bone graft healing in 1907 by Axhausen and
Phemister. The modern history of craniofacial surgery starts with French oral sur-
geon Charles Valadier (1873–1901) who directly trained otolaryngologist Sir Harold
Gillies and inspired his future work, including the first LeFort III osteotomy, though
this failed after significant relapse. Afterward, Gillies reportedly told his trainees,
“Never do that operation” (Wolfe 2011). Paul Tessier would awaken the world with
his 1967 presentation in Rome on the successful LeFort III osteotomy, now stabi-
lized with bone grafts, demonstrating that the quality of life for those with severe
facial disfigurements could be significantly improved. Before Tessier, it was thought
that the risk of infection and injury to the eyes and brain was much too high. Plastic
surgeons from all over the world flocked to Paris to learn from him, as he became
the Father of Craniofacial Surgery.
Cosmetic surgery of the face has been one of the most successful arenas for the
plastic surgeon, although at the inception of organized plastic and reconstructive
surgery, this subspecialty was looked down upon (Haiavy 2018). Cosmetic surgery
has been practiced in some form since at least 2500 BCE when skin rejuvenation
and hair growth techniques were documented in Egyptian papyrus texts. Elective
cosmetic surgery was first discussed in the late nineteenth and early twentieth cen-
turies with the development of general anesthesia.
The first publications in cosmetic surgery included Johann Friedrich Dieffenbach’s
(1792–1847) 1845 text on rhinoplasty and Robert Talbott Ely’s (1850–1885) 1881
publication on otoplasty. Jacques Joseph (1865–1934) presented his techniques on
rhinoplasty in 1898 in Berlin. Although an orthopedic surgeon by training, he is
considered the father of modern rhinoplasty and is probably the first surgeon to
dedicate their career to cosmetic surgery (see chapter Facial Cosmetic Surgery).
Today, the most common cosmetic procedure is injectables (see chapter
Minimally Invasive Cosmetic Procedures). The first noted history of fillers was in
the 1890s with the use of paraffin injections. The original use was for testicular
enlargement after tuberculosis infection. The decades leading to today have been
filled with debate on whether cosmetic surgery belongs to plastic surgery or should
be its own discipline. In 1985, the American Academy of Cosmetic Surgery (AACS)
102 G. M. Hayek and M. T. Goupil

was founded by combining multiple previous organizations and was headed by the
Father of American Cosmetic Surgery, Richard Webster. Dr. Webster, of Brookline,
Massachusetts, completed his formal training with Dr. Kazanjian in Boston. He
would eventually limit his practice to cosmetic surgery and was the principal nego-
tiator in the amalgamation of the various cosmetic surgery organizations as he
believed that plastic surgery did not equate to cosmetic surgery and that all knowl-
edge must be shared. The pure number and types of cosmetic surgery procedures
have exploded over the last half a century. Cosmetic surgery is now practiced by
members of all head and neck specialties, and fellowships dedicated to cosmetic
surgery continue to grow in number.
The culmination of plastic and reconstructive surgery of the head and neck was
achieved in 2005 with the first successful partial face transplantation in Amiens,
France (Rifkin et al. 2018). As it often does, history repeated itself with the fields of
plastic and reconstructive surgery and oral and maxillofacial surgery intertwined to
complete this most complex of operations. A new era of reconstructive surgery had
arrived, offering new possibilities for the repair of severe disfigurements. By April
2006, the first complete facial transplantation was completed in Xi’an, the capital of
Shaanxi province in China. Approximately 50 partial and complete face transplants
have now been performed worldwide as advances in allograft design, computerized
planning, surgical technique, and postoperative revision are helping to push the
boundaries.

5.2 Organizations

Kazanjian, an American dentist so instrumental in the war that he was known as the
“Miracle Man of the Western Front,” returned to Boston as professor of oral surgery
(Strother 2003). Oral surgery, however, at the time, was just beginning its own his-
tory. Kazanjian would return to medical school and by 1941 was named the first
professor of plastic surgery at Harvard University. St. Louis native Vilray Blair
returned from the war to establish a multidisciplinary team at Walter Reed Hospital
in Washington, DC, dedicated to the reconstruction of head and neck war injuries.
He was instrumental to the creation of plastic surgery as a separate specialty and
would eventually become the first non-oral surgeon elected to the American
Association of Plastic Surgeons and later a founder of the American Board of Plastic
Surgery in 1938. His assistant Robert Ivy who was dual-trained in medicine and
dentistry would form the first multidisciplinary team for the treatment of cleft lip
and palate in North America. He would remain active in professional organizations
of both plastic and oral surgery throughout his career.
From war to peacetime, the field flourished by applying techniques to own not
just an anatomical area, like the other head and neck specialties, but to become
experts in reconstructive techniques throughout the body (Poswillo 1977). Although
the earliest idea for a society of plastic surgeons appears to be brought forth in 1914
by William Shearer of Nebraska, the society known at the time as the American
Formation of Head and Neck Surgical Specialties 103

Association of Oral Surgeons (AAOS) was not formed until 1921 (Goldweyn 2008;
Lawrence 2016; Singh et al. 2015; Whitaker et al. 2007). Young surgeons returning
from World War I realized that the “unknown and impossible” reconstructive sur-
geries they were performing were not part of any known specialty.
The AAOS was formally organized by Truman Brophy (1848–1928), Henry
Sage Dunning (1880–1957), and Frederick Morehead. Membership was limited to
those with both medical and dental degrees; even Vilray Blair with his single medi-
cal degree was allowed only associate membership. In 1923, the dual-degree
requirement was dropped, though membership remained exclusive, and it would
take years before the society changed its name to the American Association of Oral
and Plastic Surgeons. In 1942, the society adopted its current name – American
Association of Plastic Surgeons.
Meanwhile, in 1931, Jacques Malinac, shunned by the American Association of
Oral Surgeons, and based on the idea by Gustave Aufricht of New York City,
founded the Society of Plastic and Reconstructive Surgery for all those “engaged in
the ethical practice of reconstructive surgery.” The name changed to the American
Society of Plastic and Reconstructive Surgeons in 1944, and the field of plastic sur-
gery remains with two major societies today.

6 Summary

The foundations of today’s head and neck specialties stem from the earliest practice
of medicine in India, Asia, Greece, and Rome. Significant contributions have been
made by the likes of the anatomists Vesalius and De Vinci. Innovations and substan-
tial contributions have been made by countless physicians from around the world
throughout the ages. There are too many of these figures to mention in this short
chapter.
The head and neck surgical specialties are primarily based on regional anatomy
with significant overlap. Surgeons of similar interests have banded together into
specialty organizations. These specialty organizations have similar goals: provide a
forum for the exchange of ideas, education for current and future providers, research
to improve diagnostics and treatments within the specialty, and the setting of high
ethical standards to protect the interests of the patients they serve.

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 Part II
Conventional Procedures
Head and Neck Infections

Justin Fazzolari, Bridget Ferguson, and Sidney B. Eisig

1 Prehistory

To understand the history of maxillofacial infections, we will begin by examining

their impact on humans over time. Early human experience with maxillofacial
infections may not have mirrored our own modern experiences. Fortunately for us,
the fossil record is incredibly useful for this purpose, and abundant, well-preserved
skulls from various eras and geographic locations tell a story of how these infections
played out.
Teeth number among the hardest tissues in the human body. Furthermore, they
tend to remain embedded in alveolar bone long after a person’s death. The fossil
record unsurprisingly offers a measure of an individual’s dental health and snapshot
of chronic or acute maxillofacial infections present at the time of death.
The earliest record of periapical abscesses dates back to two million years BCE,
found in an individual from our own genus, Homo. In this individual, abscesses
originating directly from the apices of multiple incisors point toward the presence
of significant odontogenic infection rather than systemic osteolytic disease. It has
been suggested that the severity, number, and unhealed state of the infections may
indicate they contributed to the individual’s death (Towle and Irish 2019).
While definitive evidence for maxillofacial infections in our most ancient ances-
tors certainly exists, it is important to note the relative scarcity of dental pathology
in the oldest fossils. Caries rates as low as 3% have been noted in populations of
early hominids (Grine et al. 1990). Rates of caries varied across time and location
even within a single species, suggesting behavior and dietary habits played a key

J. Fazzolari · B. Ferguson · S. B. Eisig (*)

Oral and Maxillofacial Surgery, Columbia University Irving Medical Center,
New York, NY, USA
e-mail: [email protected]; [email protected];
[email protected]

© The Author(s), under exclusive license to Springer Nature 107

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_8
108 J. Fazzolari et al.

role in rates of odontogenic infection (Nicklisch et al. 2016). There is one thing all
our predecessors have in common, however: significantly lower caries rates than
modern humans.
A look at our closest surviving relatives, apes, reveals a different cause for most
maxillofacial infections: severe attrition and trauma leading to tooth fractures and
pulp exposures (Legge 2012). This is borne out by examining fossils from humans
just prior to the agricultural revolution, wherein high rates of attrition are thought to
have obliterated carious lesions as they formed, lessening their impact (Lieverse
et al. 2007).
Additionally, pulpal exposure by gradual attrition was less likely to lead to the
severe periapical abscesses that we are accustomed to seeing today. It has been pos-
ited that the “abscesses” recorded in many of our ancestors’ maxillae and mandibles
may actually represent more benign lesions: “Such periapical granulomata and api-
cal periodontal cysts, with far less serious implications for the health of the indi-
viduals. Individuals with multiple periapical cavities … were not, therefore,
necessarily ill” (Dias and Tayles 1997).
The most significant historical development in terms of maxillofacial infections
is undeniably the agricultural revolution. Changes in our diet and food preparation
techniques ushered in previously unseen levels of dental decay and associated infec-
tions (Eshed et al. 2006). Modern humans, in fact, appear to suffer from the highest
rates of dental caries compared to all populations throughout history. Caries has
eclipsed attrition and trauma as the #1 cause of odontogenic infections, which have
implications for detection, diagnosis, and management (Stránská 2013).
This transition from high rates of attrition to low rates of caries in prehistory to
the high caries rates of modernity sets the stage for our modern understanding of
odontogenic infection and head and neck infections. This understanding has been
characterized by severe, fulminant infectious illness from caries-induced abscesses,
with acute loss of bone and potentially lethal spread into various deep spaces of the
head and neck. The shift toward this mechanism of disease would dictate both our
understanding of maxillofacial infections and our treatment of them over the course
of history.

2 Treatment of Infection in Antiquity

Introduction: Throughout most of human history, limited medical knowledge

meant that few effective treatments were available to those suffering from disease.
As nomadic hunter-gatherers began to develop permanent, agriculture-based settle-
ments, technology advanced and written language began to emerge. Before long,
the origins of medical and surgical treatment started to take hold in increasingly
specialized societies. Many of the advances and beliefs that were written down sur-
vive to today, providing a glimpse into the knowledge base and treatments of ancient
peoples.
Head and Neck Infections 109

Ancient Egypt: Some of the earliest known writings pertaining to the treatment of
maxillofacial infections can be traced back to ancient Egypt, a civilization at its
peak from approximately 3000 BCE–1000 BCE. Our knowledge of the ancient
Egyptians is sourced from translations of original medical accounts from papyrus,
wood carvings, and inscriptions on tombs and monuments (Figs. 1 and 2). Much of
this information is quite specific and rich in detail, with formal titles for medical
professionals such as surgeons and dentists referenced in original texts
(Forshaw 2009).
Despite a plethora of information about ancient Egyptian medical practices, evi-
dence is sorely lacking to support the surgical treatment of maxillofacial infections
or even simple tooth extractions. Some scholars go so far as to “strongly reject” that
dental surgery or abscess drainage was routinely performed (Blomstedt 2013). No
instruments for dentoalveolar surgery have ever been discovered (Forshaw 2009)
(unlike for many other cultures), and human remains consistently demonstrate peri-
odontally involved teeth that could easily have been extracted but were not (Miller
and Fields 2009).
Instead, it appears that treatment of odontogenic infections mainly involved
applying pastes and masticatories directly to the painful site—treatment of a medi-
cal rather than surgical nature (Guerini 1909). Some of these treatments may have
had mild analgesic effects, but the actual efficacy of these medicaments is highly
dubious. A number of complex recipes have survived until modern times, seen
above. Despite being so advanced for an early culture, it appears very little was done
for maxillofacial infections in ancient Egypt, with maxillofacial surgery a rarity.
Greece and Rome: Following the relative decline of Egyptian power, ancient
Greek culture rose to prominence in the Mediterranean and began making its own
contributions to medical and surgical understanding. A number of influential Greek
physicians laid the groundwork for the expansion of formal medical education and
training in prosperous regions.
Surviving texts indicate that the Greeks respected ancient Egyptian medicine,
although it is difficult to determine precisely which Greek practices derived from
Egyptian methods. Greek medicine originated with a heavy focus on mysticism,
which oftentimes implicated divine intervention in sickness and in health. This
framework evolved over time into more rational, cause-and-effect style reasoning,

Fig. 1 Egyptian
hieroglyphs on papyrus
detailing a recipe for
medical treatment of
odontogenic infection
(Guerini 1909)
110 J. Fazzolari et al.

Fig. 2 English translation

of Egyptian recipe for
medication to treat
odontogenic infection
(Guerini 1909)

even if this was dominated by beliefs about balances and imbalances of “humors”
we consider erroneous today. Roman medicine largely carried on and advanced the
medical theory of Greece, so we will discuss these two cultures together.
The Greeks and Romans, like the peoples before them, placed a heavy emphasis
on the application of medicaments in the forms of pastes, poultices, and masticato-
ries with regard to the oral and maxillofacial region. One of the most significant
departures from previous eras, however, is the emergence of surgery as a legitimate
treatment option.
The work of Aulus Celsus (n.d.-a, n.d.-b), a Roman encyclopedist in the first
century, represents one of the most complete primary sources of medical knowledge
in Roman times. Entire paragraphs dedicated to the medical and surgical treatment
of maxillofacial infections can be found in his compilation De Medicina. These pas-
sages demonstrate the understanding in Rome that proper treatment may require
both medical and surgical interventions. We will quote three of these segments
at length:
In the mouth too some conditions are treated by surgery. In the first place, teeth sometimes
become loose, either from weakness of the roots, or from disease drying up the gums. In
either case the cautery should be applied so as to touch the gums lightly without pressure.
The gums so cauterized are smeared with honey and swilled with honey wine. When the
ulcerations have begun to clean, dry medicaments, acting as repressants, are dusted on. But
if a tooth gives pain and it is decided to extract it because medicaments afford no relief, the
tooth should be scraped round in order that the gum may become separated from it; then the
tooth is to be shaken. This is to be done until it is quite moveable: for it is very dangerous
to extract a tooth that is tight, and sometimes the jaw is dislocated. With the upper teeth
there is even greater danger, for the temples or eyes may be concussed. Then the tooth is to
be extracted, by hand, if possible, failing that with the forceps. (Celsus n.d.-a)
But a hot poultice made of flour and a fig is then to be put on until pus is formed there: then
the gum should be cut into. A free flow of pus also indicates a fragment of bone; so then too
it is proper to extract the fragment; sometimes also when the bone is injured a fistula is
formed which has to be scraped out. But a rough tooth is to be scraped in the part which has
become black, and smeared with crushed rose-petals to which a fourth part of ox-galls and
the same amount of myrrh has been added; and at frequent intervals undiluted wine is to be
held in the mouth. (Celsus n.d.-a)
Head and Neck Infections 111

Should suppuration show itself, it will be necessary to use the above mentioned steam for a
longer period; to keep in the mouth hot mulse, in which some figs have been cooked, and to
lance the tumor before it is perfectly ripe, so that the pus may not, by remaining too long in
the diseased part, injure the bone. But if the tumor be of great size, it will be more advisable
to remove it entirely, so that the tooth remain free on both sides. After the pus has been
extracted, if the wound be a small one, it is sufficient to keep hot water in the mouth, and to
use externally fomentations of steam, as mentioned above; if it be large, it will be fitting to
use the decoction of lentils and the same remedies with which all other ulcers of the mouth
are cured. It also happens, sometimes, that from an ulcer of the gums—whether it follow a
parulis or not—one may have for a long period a discharge of pus, on account of a broken
or rotten tooth, or else on account of a disease of the bone; in this case there very often
exists a fistula. Then the latter must be opened, the tooth extracted, and if any bony frag-
ment exist, this should be removed; and if there be anything else diseased, this should be
scraped away. Afterward, the same remedies which have been indicated for the other ulcers
of the mouth must be used. (Guerini 1909)

The above passages help illuminate the contemporary knowledge of odontogenic

infection by the time of ancient Rome. Celsus documents a sophisticated under-
standing of the relationship between dental decay and infections. By this time, it
was widely accepted that a decayed or fractured tooth could lead to abscess devel-
opment in the jawbones, which should then be treated by incision and drainage of
the abscess, removal of the offending tooth, curettage of the site, and removal of
bony sequestra—hallmarks of treatment which are still practiced today.
The earliest known specialized instruments for maxillofacial surgery can be
traced to this era. Archaeological digs and surviving medical texts from the era
showcase instruments recognizable to surgeons today. These instruments, shown
below (Figs. 3 and 4), include bone levers, bone forceps, osteotomes, scalpels,

c
Scalpels
A. artfacts00210
8in / 20.3cm
B. artfacts00167
d 6in / 15.2cm
C. artfacts00169
5.625in / 14.3cm
D. artfacts00168
e 5.625in / 14.3cm
E. artfacts00165
4.625in / 11.7cm

Fig. 3 Scalpels from ancient Rome in the first century CE. (Courtesy of Historical Collections &
Services, Claude Moore Health Sciences Library, University of Virginia)
112 J. Fazzolari et al.

Fig. 4 Bone levers, also

used to extract teeth, from
ancient Rome in the first
century CE. (Courtesy of
Historical Collections &
Services, Claude Moore
Health Sciences Library,
University of Virginia)

cauteries, and curettes—all necessary tools in an armamentarium for maxillofacial

surgery. There is also mention of bone files, rasps, and tooth elevators from Galen,
a Roman physician in the second century.
Taken together, these records make it abundantly clear that maxillofacial surgery
had considerably advanced by the time of the late Roman Empire. It is important,
however, to balance this knowledge with the reality that surgery was still a danger-
ous and unpredictable affair. It often represented the last resort for an affliction that
would not resolve on its own. We will leave the Romans with this: “The ancients
regarded tooth extraction as an operation to be avoided wherever possible. Caelius
Aurelianus says death had followed in some cases, and that in the temple of Apollo
at Delos there hung a tooth forceps of lead as a reminder for operators to exert little
force in tooth extraction” (Milne 1907).
Islamic Medicine: After the fall of Rome, progress in the medical field stagnated
across much of Europe. Meanwhile, Islamic scholars were hard at work preserving,
translating, and advancing many of the medical practices that came before it
(Campbell 2013). In many ways, Arab cultures picked up where the ancient Greeks
and Romans left off. Their approach to the provision of medical care—in dedicated,
academically oriented hospitals rather than the ad hoc practice settings of the past—
allowed for both the centralization and institutionalization of medical care and sur-
gery. These hospitals gave Islamic physicians centers to practice medicine, learn
from others, and pass knowledge and skills to their trainees (Pormann and Savage-­
Smith 2007).
While medical care as a whole advanced in Islamic society, physicians of the
time were still hesitant to engage in surgery due to the significant risks involved and
low success rates. Even procedures with favorable success rates in Greek and
Roman literature were not necessarily embraced by Islamic doctors (Pormann and
Savage-Smith 2007). When surgical procedures were performed, however,
Head and Neck Infections 113

practitioners were known to engage in antisepsis, a practice not widespread in previ-

ous eras, and proper hygiene was emphasized in medical settings. Islamic surgeons
pioneered the use of catgut sutures to close wounds, laying the groundwork for the
various types gut-style sutures we use today (Amr and Tbakhi 2007).
Despite these advances, maxillofacial surgery was not particularly changed, and
many erroneous notions persisted. As late as the eighteenth century, “tooth worms”
(Fig. 5) were blamed for dental problems and associated infections. Some emphasis
was made on dental hygiene, which may have helped prevent infections (Boss
1993), but the treatment of maxillofacial infections once they developed was sub-
stantially unchanged.
Medieval Europe: For several centuries after the fall of Rome, medicine in Europe
made minimal advances. Literacy declined and populations de-urbanized, leading
to a significant decrease in learning and knowledge transfer (Riché 1976). Roman
medical practices continued in southeastern Europe as part of the Byzantine Empire,
although language differences (Latin vs. Greek) kept Western Europe more or less
in the dark (Stahl 1962).
Despite these troubles, organized society began to coalesce again around
1000 CE in Western Europe, and with it, a revival in learning. Universities began to

Fig. 5 Eighteenth-century
hand-illustrated page from
Ottoman dental book
depicting tooth worms
114 J. Fazzolari et al.

emerge, and eventually, the translation of Greek, Latin, and Islamic texts renewed
interest in medicine (Hunt 1992). Within these universities, formal dissections and
autopsies were practiced like never before, greatly advancing knowledge of surgical
anatomy (Bylebyl 1979).
Treatment of oral and maxillofacial conditions do not appear to have been sig-
nificantly improved from previous practices discussed. The usual erroneous beliefs
prevailed (tooth worms, humours, etc.), while treatment often relied on herbal rem-
edies of dubious efficacy. Tooth extractions were performed generally by laypeople
or barber-surgeons.
Notably, rates of dental caries appear to have been relatively low in medieval
populations. Modern studies of medieval archaeological samples generally estimate
the prevalence of caries to have been below 20% (Moore and Corbett 1971, 1973,
1975). Numerous factors are likely to cause for this, including a diet high in vegeta-
bles and low in refined carbohydrates (DeWitte and Bekvalac 2010). It is reasonable
to infer from these low caries rates that severe odontogenic infections were not
encountered with great frequency during this period in time.
Although not specific to the maxillofacial region, the experience of the bubonic
plague is worth briefly discussing as it appears to have emboldened physicians of
the time to more frequently surgically intervene in cases of frank infection: “We do
not wait for the Suppuration of a Buboe until it breaks of itself, when the Pain and
other Symptoms continue very severe without Remission; besides, there would in
doing so be Danger of wasting the Spirits too much, and letting the morbifick Matter
retreat, besides the Smalness of the Orifice, which when they open themselves, is
seldom large enough to give due Vent; we therefore open them by Incision, or to
prevent Mortification, by a potential Cautery” (Hodges and Quincy 1720).
Early Modern Period: As we remarked in earlier paragraphs, archaeological evi-
dence indicates significantly lower rates of dental caries across historical periods
than we are accustomed to today. This all began to change, however, during the
early modern period, generally considered to have begun in the early 1600s. Around
this time, dietary habits began to change as refined sugar became available at a scale
never before experienced (Clarke 1999).
With changes in diet, dental caries and odontogenic infections began to drasti-
cally increase in prevalence. By consulting the London Bills of Mortality from the
1600s, we can see that “teeth” were consistently listed among the leading causes of
death (Hull 1964; Weinberger 1948). Meanwhile, Dutch artists began depicting
decayed dentition on most individuals in their artwork as the sugar-refining industry
boomed around Amsterdam (Clarke 1999).
Dental infections were commonplace in the New World as well (Clarke 1999).
Cadwallader Colden, a colonial New York governor and physician, remarked about
the typical appearance of a young boy of the era: “He is pale of complexion, has bad
teeth and often troubled with the toothache but as this is endemial to the country so
that not one in a hundred of those born have good teeth or are free from toothache”
(Weinberger 1948).
Head and Neck Infections 115

Unfortunately for those suffering from maxillofacial infections at the time,

understanding of the disease process was incomplete and still tied to the faulty
notion of “internal humours” (Guerini 1909). Treatments were similarly archaic.
Cupping, cautery, medicaments, and bloodletting remained the mainstay of medical
treatment of maxillofacial infection (Guerini 1909).
By the early 1700s, surgical literature began to more consistently endorse inter-
ventions such as incisions and drainage of odontogenic abscesses: “the opening in
time of abscesses of the gums and of the palate even before they be completely
matured, in order to prevent the suppurative process from extending and damaging
the bone below” (Mauquest de la Motte 1732). Surgeons also demonstrated an
understanding that bone loss is frequently involved in maxillofacial infections, a
key step in understanding the disease process overall.
Pierre Fauchard’s book Le Chirurgien Dentiste was among the first modern pub-
lications of scientific dentistry which documented the development, progression,
and treatment of odontogenic infections:
The patient was suffering with a large abscess on the right side of the lower jaw, accompa-
nied by such great swelling of the cheek that it was impossible to open the mouth wide
enough to examine the teeth. [The surgeon] Juton proposed opening the abscess immedi-
ately, but the patient would not consent. The following day he was sent for in great haste.
The gathering had changed its seat, making its way between the skin and muscles of the
neck, where it now formed so huge a tumefaction that the patient was in danger of being
suffocated. The abscess was now immediately opened, but the swelling of the face still
persisted; it was therefore only after a month had elapsed that it was possible to extract the
root of the last molar, which had been the original cause of the whole malady. The surgeon
observed that the liquid injected into the fistulous opening in the neck issued from the
alveolus of the last molar. After the extraction of the root a prompt recovery was effected.
(Spielman 2007)

German dentist Philip Pfaff arrived at a similar conclusion and stated forcefully
in his textbook Treatise on the Teeth of the Human Body and Their Diseases:
“Gingival abscesses as well as fistulae of the maxillary region almost always owe
their origin to decayed teeth, and can, therefore, in general, not be cured except by
the extraction of these teeth”(Guerini 1909).
Foundations of Modern Understanding: By the nineteenth century, scientific
and technological advances began to accelerate at a rate never before seen. Many of
the advances in knowledge around this time laid the most fundamental groundwork
for our modern understanding of infectious disease. Perhaps most influential of
these to our discussion is the widespread acceptance of “germ theory”—the idea
that microscopic organisms could invade human tissue, causing disease. Germ the-
ory overthrew the long-held “miasma” theory which gave credit to foul air spread-
ing disease (Last 2007).
WD Miller, a dual-degree American dentist, was a leader in the application of
germ theory to the mouth, characterizing and classifying numerous microbes he
cultured from maxillofacial infections. Miller was a strong proponent of the theory
that dental caries were directly related to the by-products of bacterial colonization.
116 J. Fazzolari et al.

He posited in 1891 that “the human mouth, as gathering-place and incubator of

diverse pathogenic germs, performs a significant role in the production of varied
disorders of the body.” He characterized odontogenic infections as follows:
Alveolar abscess is an infectious disease, primarily of local character, but frequently, or
usually, accompanied by general symptoms of varying intensity, and sometimes attended
by complications of most serious nature. Severe cases of alveolar abscess, particularly in
weak persons, not unfrequently present symptoms of an alarming nature. The extensive
oedema, general debility, fever, chills, forcibly suggest the thought of general infection,
which, it must be admitted, is always possible where large masses of pus accumulate about
the point of the root. General blood-poisoning (septicaemia), with speedily fatal termina-
tion, has been seen to result from accumulations of infectious material about the roots of
tooth. (Miller 1891)

Miller goes on to describe common and serious complications from odontogenic

infections and mandibular fractures, including osteomyelitis, mediastinitis, and
Ludwig’s angina. He describes a dangerous route of spread familiar to us today as
progressing “through the floor of the mouth and retrotonsillar tissue into the medi-
astinum, producing pleuritis, pericarditis, etc., with purulent exudations.” He con-
sidered it highly probable based on the evidence available at the time that
maxillofacial infections are “the result of the invasion of micro-organisms through
slight wounds, ulcerations, or other breaks in the continuity of the mucous mem-
brane, or by way of diseased teeth, or of the tonsils, or of the ducts of the sublingual
and submaxillary glands”(Miller 1891).
Indeed, the most remarkable development of the late nineteenth century is the
shift in the understanding of how maxillofacial infections arise. Rather than viewing
each type of infection as its own discrete entity, with varying and often superstitious
associated treatments and causes, scientists of the time rightly began to view them
simply as differing manifestations of the same broad phenomenon, the same over-
arching theme: invasion of body tissue by microorganisms (Miller 1891).
So central to our understanding of maxillofacial infections, this idea became that
scientists like WD Miller dedicated their careers to meticulously observe and docu-
ment the properties of the microorganisms found in each case they encountered.
Although much remained to be learned, patterns began to emerge and names similar
to those used today began to be assigned to various species: Bacillus dentalis viri-
dans, Streptococcus septopyaemicus, , Actinomycesetc.
Around the turn of the twentieth century, a more advanced understanding of
infectious disease was becoming widespread in medical literature. By examining
contemporary research into Ludwig’s angina in particular, we are able to glean con-
siderable insight into the ideas of the time with regard to what was considered
“acute septic infection of the throat and neck.” In a 1906 Annals of Surgery article,
Dr. Gwilym G. Davis lays out several points which must be known to adequately
understand the pathology of a disease:
(1) what is the germ or germs that start the infection; (2) how do they gain access to the
tissues; (3) what tissues are attacked; (4) how the infection progresses; (5) how it influences
the parts locally and, finally, (6) how it affects the system generally. (Davis III 1906)
Head and Neck Infections 117

In the same article, Davis makes clear that oftentimes, one bacterial species pre-
dominates but that mixed infections are also common. The thoroughly modern
understanding of maxillofacial infections was thus outlined: “When the teeth are the
starting point the inflammation involves the periosteum of the lower jaw and thence
invades all the surrounding tissues… No matter how it commences, it spreads along
the connective tissues by direct continuity. It is not transmitted by the lymphatics”
(Davis III 1906). With regard to Ludwig’s angina in particular, he demonstrates an
understanding that edema is the main issue with pus forming secondarily.
By this time, odontogenic sources had been identified as the most common cause
of Ludwig’s angina. Despite this, dentists were loath to treat it properly for fears of
liability. As explained by Davis, “dentists will neither extract the offending tooth,
nor open the abscess, nor attempt any operative means of relief for fear they should
be held accountable for subsequent results.” This is considered a mistake, as Davis
states, “I am firmly convinced that the disease in its early stage is a purely local
affection whose extension can be promptly cut short by fearless surgical treat-
ment… In edema of the epiglottis and larynx, ice and inhalations (spray) of cocaine
and adrenaline may be of service, but tracheotomy should not be deferred too long”
(Davis III 1906). Prior to antibiotics, surgeons of the time had only a short to win-
dow to intervene before infection overwhelmed.
The above advanced understanding of Ludwig’s angina should be contrasted
with Ludwig’s own explanations, only 60 years earlier: “Therapy was decided upon
after consideration of the season of the year, epidemic-like character of the illness…
and was chiefly as follows: local and general blood-letting, softening poultices and
cataplasms, external and internal use of mercurial, relief of spasm by the remote
application of sinapisms and vesicants; cathartics, diuretics and diaphoretics accord-
ing to momentary requirements; in the later stages of the disease, local irritants
according to the degree of the mortification process, and internal medications for
the typhus process, directed particularly to the head and chest organs” (Burke 1939).
Mentions are made of the dangerous effects of letting patients “catch cold,” an idea
now understood to be unrelated to the development of infection.
Advances in the understanding of infectious processes were in no way limited to
treatment of acute septic maxillofacial infections. Similarly in trauma cases, it
became understood that the retention of teeth in fracture lines allowed oral bacteria
unimpeded access to internal tissue. In cases of osteomyelitis, complete excision of
necrotic bone was emphasized to remove foci of infection. In just a short time, germ
theory revolutionized our understanding of infectious disease and appropriate
treatments.
Asepsis: In studying germ theory, pioneering lab scientists like Louis Pasteur
understood that surgical and lab instruments could harbor microbes of their own,
thereby causing contamination of any environment into which they are introduced.
Pasteur subsequently demonstrated the effectiveness of heat sterilization in prevent-
ing the spread and replication of microbes (Ligon 2002). It might be expected that
the same principles would naturally carry over to surgical procedures, but the adop-
118 J. Fazzolari et al.

tion of antiseptic or aseptic techniques by surgeons was uneven and significantly

delayed from its adoption in labs. When physician Ignaz Semmelweis advocated for
the careful washing of hands to reduce hospital infections, his findings were initially
met with disdain and fierce resistance (Semmelweis 1983).
One of the early proponents of aseptic technique, Joseph Lister, published his
first article with the use of carbolic acid antisepsis in The Lancet in 1867 (Lister
1867a). Lister was a strong proponent of asepsis, and over time, other surgeons
began following similar techniques. Not all surgeons agreed that germ theory was
necessarily to blame for postsurgical infections, but they could not argue with the
published and reproducible results from adhering to aseptic technique—higher sur-
gical success rates and fewer complications (Lister 1867b).
By the 1890s, papers were being published in medical literature regarding the
use of antiseptics and disinfectants specifically in dental surgery (Miller 1891). The
antiseptics detailed had differing uses—some for the application to instruments,
some to be applied directly to surgical sites, and still others for use as mouth rinses
(Gish 1888). The use of such antimicrobial substances both improved the safety of
surgical interventions in head and neck infection cases and simultaneously reduced
the incidence of infections secondary to other maxillofacial surgeries. Gradually,
more and more surgeons came on board with the practice of aseptic technique.
These ideas eventually formed the basis for practices we follow today in surgically
treating maxillofacial infections—the use of sterile instruments, chlorhexidine
rinses, and povidone-iodine preps, among others.
The Antibiotic Era: In the late nineteenth century, scientists around the world
began noting the inhibitory effects on bacterial growth exhibited by the presence of
certain types of mold. In 1928, so the story goes, Alexander Fleming discovered the
substance penicillin (Tan and Tatsumura 2015). Chemists succeeded in purifying
penicillin, and the drug saw widespread use as the first highly effective systemic
antibiotic in the 1940s (Mestrovic 2010).
These developments which revolutionized the treatment of infectious diseases
unsurprisingly had major impacts on the treatment of maxillofacial infections. As
early as 1947, Dr. Kurt Thoma, an American oral and maxillofacial surgeon, began
addressing these changes: “In some instances, these new agents are so effective that
surgical interference is eliminated, while in others they make possible earlier surgi-
cal measures with greater safety to the patient and a more rapid convalescence. In
most instances, however, the use of antibiotics combined with carefully planned and
adequate surgery gives the best results” (Thoma 1947).
Wound cultures took on even greater importance as the identification of caus-
ative microbes could now directly influence treatment. Thoma encouraged a “thor-
ough bacteriologic study” of all cases and advised physicians to avoid contamination
of culture samples from other microbes present in the mouth (Thoma 1947).
We also begin to see at this time the balancing act of when to consider conserva-
tive treatment with antibiotics versus an urgent tooth extraction. Timely initiation of
antibiotic treatment was found to be adequate for some limited types of cases, but
Head and Neck Infections 119

for many others, it was clear that a timely extraction remained necessary to defini-
tively cure the condition. In any case, the use of antibiotics was found to greatly
improve the safety profile of necessary surgical interventions such as extractions
and incision and drainage (I&D) procedures. As remains the case today, however,
Thoma noted, “Many patients do not present themselves for treatment early enough,
however, and require elimination of accumulated pus and excision of dead bone”
(Thoma 1947).
The promise of antibiotics was so great that surgeons of the time began to experi-
ment with different methods of drug delivery. Systemic administration of penicillin
had already been found to have significant effects on bacterial infection, even with
low circulating concentrations in the blood. Surgeons surmised that higher local
concentrations may be beneficial when applied directly to infected sites. To achieve
this, rubber catheters were frequently left in difficult-to-treat infections such as
osteomyelitis to allow antibiotics to be “instilled” directly into the site (Thoma
1947; Coe 1951).
By the middle of the twentieth century, surgeons were advocating for supportive
care regimens similar to what is used in hospitals today (Thoma 1947). Foremost,
antibiotics were recommended to be continued until all signs of infection abated.
Proper nutrition, fluid management, and oral hygiene were seen as crucial to recov-
ery and the prevention of secondary infection. Even the penicillin-based drugs most
commonly used to treat odontogenic infection today are direct descendants of the
drugs pioneered at this time.
Unsurprisingly, not all practices remain prevalent—Dr. Thoma advocated that
“repeated blood transfusions greatly aid in improving the general condition of den-
tal patients afflicted with chronic suppuration and help to overcome the infection,”
a treatment modality unthinkable today.
Diagnostic X-Ray Imaging: For most of human history, physicians had limited
tools at their disposal for diagnosing infections: the symptoms reported by the
patient and the physical signs observed upon examination. This would all change
after William Roentgen used his first X-ray in 1895. In less than 30 years from its
first use, X-ray imaging was widely used in dentistry, and radiography became a
compulsory component of professional education (Read 1925).
The plain radiographs (Fig. 6) available for most of the century were incredibly
useful to dentists and physicians looking to localize the source of an infection in the
maxillofacial region. The jawbones lend themselves well to diagnostic imaging as
regions of resorbed bone associated with odontogenic infection are readily visible.
With the ability to accurately diagnose sources of odontogenic infection, treatment
could be targeted to the involved teeth while sparing vital ones.
Encouraged by the successful and widespread adoption of diagnostic X-ray
imaging, researchers in the early 1900s experimented with additional applications
of the novel technology. Undesirable effects of ionizing radiation well known to us
today—skin burns, hair loss, etc.—were noted relatively early into its adoption. The
same process that damaged our cells, however, also appeared to damage the cells of
microbial invaders. Before long, doctors were directly irradiating infected tissue to
120 J. Fazzolari et al.

Fig. 6 Two-dimensional
radiographic view of
posterior tooth with
periapical abscesses.
(Coronation Dental
Specialty Group, CC
BY-SA 3.0 https://
creativecommons.org/
licenses/by-­sa/3.0, via
Wikimedia Commons)

neutralize infection and promote healing (van Dijk et al. 2020). The mechanism was
suggested to be a combination of direct effects on bacterial populations and host
immune alterations that enhanced phagocytosis (Calabrese 2013).
The medical community of the time generally accepted that X-ray irradiation
could serve as an effective adjunct to surgery and sometimes a superior alternative.
As late as the 1940s, cases of cellulitis secondary to maxillofacial surgery are
reported in the literature as being treated with ionizing radiation in conjunction with
antibiotic therapy. Despite being an apparently effective treatment for soft tissue
infections, the use of X-rays began to fall out of favor as more serious side effects
started to come to light—in particular, associations with salivary gland neoplasms
(Schneider et al. 1998). The availability of a wider range of more effective antibiot-
ics over time effectively rendered the technology obsolete.
In the 1980s, the availability of CT (computed tomography) imaging further
expanded the capabilities of radiography in treating head and neck infections. For
the first time, doctors could visualize “slices” of the imaged region, allowing a
three-dimensional analysis of exactly where infections lay. The contributions from
this technology were summed up as follows in a 1985 article in The Laryngoscope:
The influence of CT scanning on therapy of masticator space infections and tumors is pro-
found… CT determines the need for surgery in infections by differentiating cellulitis from
abscess formation. When abscess formation is present, CT defines the best surgical approach
and positioning of drains. It can demonstrate osteomyelitis and unsuspected abscesses.
Postoperatively, CT can determine the presence of undrained abscesses. (Doxey et al. 1985)

This notion was corroborated by many surgeons of the time, including a 1982
article by Flood et al. which praised CT scanning for its utility in localizing infec-
tion and planning surgical approaches to odontogenic infections with orbital
involvement (Flood et al. 1982).
Head and Neck Infections 121

Development of Contemporary Evidence-Based Care: As the medical literature

matured and high-quality studies were conducted with greater frequency, we began
to amass greater knowledge of the safest and most effective ways to manage maxil-
lofacial infections. This fund of knowledge allowed practitioners of the mid- to late
twentieth century to refine practices and recommend effective treatments while
abandoning less favorable options.
For example, in the early 1900s, chlorophyll garnered some degree of notoriety
as a potential game-changing treatment for maxillofacial infections due to appar-
ently favorable results in initial studies (Gruskin 1940). As more studies emerged,
however, the efficacy of this treatment came into question, with more rigorous anal-
yses showing little to no benefit. Coupled with the availability of efficacious antibi-
otic alternatives, chlorophyll faded from use to the point that few practicing surgeons
would consider its use today.
Similarly, the “instillation” of antibiotic solutions directly into wounds previ-
ously discussed became less prevalent as doubts over its effectiveness and concerns
about costs and antibiotic resistance emerged. Several studies through the early
twenty-first century claimed no benefit for bacterial killing with the irrigation of
wounds with combination antibiotic solution (Goswami et al. 2019). Evidence
against this practice mounted to the point that international researchers, including
those at the 2018 International Consensus Meeting on Musculoskeletal Infection,
voted strongly against the use of polymyxin-bacitracin in wound irrigation solutions
(Dyrda 2018).
On the other hand, concrete evidence of efficacy in medical literature has allowed
better practices to disseminate throughout the community more uniformly. One
such example is the use of antibiotic prophylaxis to prevent infections related to
maxillofacial surgery. Preventing an infection is undoubtedly preferable to treating
one, although this must be weighed against potential complications from antibiotic
treatment. Currently, literature supports perioperative antibiotics in the case of open
trauma surgery (ORIF) and orthognathic surgery, but not routine dental extractions
(Zallen and Curry 1975; Kreutzer et al. 2014).
Once an infection has developed, there still exists some debate on when surgical
intervention is warranted. Recent reviews such as a 2017 study in Oral and
Maxillofacial Surgery Clinics have suggested a less aggressive approach to treating
infections may be reasonable, given the availability of highly effective broad-­
spectrum antibiotics. The authors recommend limiting surgical incision and drain-
age to “spaces that have identifiable purulent collections” and argue that cellulitis
may be managed medically so long as the source of infection is removed (Taub
et al. 2017).
Furthermore, consensus in the medical literature can confirm the utility of estab-
lished practices and support their continued use. Recent studies have demonstrated
that the combination of clinical examination with contrast CT imaging is signifi-
cantly more effective than either option on its own (Miller et al. 1999).
As new technologies emerge and established practices are scrutinized, we can
expect the treatment of maxillofacial infections to continue to evolve. Today’s
122 J. Fazzolari et al.

sterile and highly controlled operating rooms are a far cry from our barber-surgeon
roots. Antibiotics and radiographic technologies now provide surgeons with
improved tools to quickly combat head and neck infections and avoid morbidity and
mortality.

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Evolution of Tooth Removal

Michael T. Goupil and Vernon Burke

1 Introduction

The removal of teeth is most likely one of the earliest surgical procedures per-
formed. Probably, the first tooth was removed from a blow to the face, either acci-
dently or as part of an interpersonal altercation. It is speculated that the first
purposeful removal of a tooth was accomplished with the “the ancient healer using
a hickory stick and stone mallet” (Bremner 1954, p. 341).
Over time, the removal of teeth became a specialized niche within medicine.
Specific instruments were developed, but the primary tooth removal instrument, the
forceps, has not changed dramatically since ancient times.
The removal of teeth, including impacted third molars, continues to be one of the
most common surgical procedures performed today. Oral surgeons over the recent
past have established the indications, classification systems, risk-benefit analysis,
and surgical methods employed by the vast majority of oral and maxillofacial sur-
geons worldwide.

M. T. Goupil (*)
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
Consultant in Oral and Maxillofacial Surgery, Carmel, IN, USA
V. Burke
High Desert Oral & Facial Surgery, El Paso, TX, USA

© The Author(s), under exclusive license to Springer Nature 125

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_9
126 M. T. Goupil and V. Burke

2 Ancient History

2.1 Prehistory Humans

The intentional removal of teeth dates to the Stone Age and most likely makes it one
of the first surgical procedures performed by humankind. There is evidence that one
or more incisors were intentionally removed in the late Stone Age (prior to
10,000 BCE). Evidence from both Asia and North Africa indicate that these teeth
were not removed for pathological purposes but more likely to represent a signifi-
cant social event such as the onset of puberty and social maturation (De Groote and
Humphrey 2016; Willman et al. 2016). Most likely, these surgical procedures were
performed by an ancient healer using a hickory stick and a stone mallet (Wynbrandt
1998, p. 5; Bremner 1954, p. 341) (Fig. 1).
The course diet of the Stone Age people, where the food was mixed with sand
and gravel, would lead to severe tooth abrasion. The result of this abrasion would be
severe pain and pulp necrosis. It is quite likely that this pain would lead to tooth
removal. Our Neolithic ancestors may have used the finger and thumb to remove
teeth (Anonymous 1914, p. 10).
With a change to a farming culture, more than 12,000 years ago, an increase in
caries was noted. There is evidence that there was tool-assisted manipulation to the
tooth in an attempt to remove the necrotic or infected pulp (Oxilia et al. 2015, 2017).
The use of a flint drill was used to treat caries in the Neolithic period (Coppa
et al. 2006).

2.2 Eastern and Egyptian Era

There were traces of “one who treats teeth” found at the Step Pyramid of King
Djoser (Hoffmann-Axthelm 1981b). At that time, Hesy-Rei was considered to be
the first dentist and dates back to 2500–2600 BCE (Leek 1967). Since dental disease
was considered to be caused by spirits, treatment usually consisted of incantations,

Fig. 1 Stone Age mallet.

(Image of the public
domain)
Evolution of Tooth Removal 127

magic spells, and prayers (Wynbrandt 1998, p. 11). Most of the dental treatment
was restricted to pharmaceutical preparations which did little to alleviate the wide-
spread and painful dental disease (Forshaw 2009).
The often-quoted Ebers Papyrus, written around 1550 BCE, is among the oldest
written works on medicine and is believed to contain material dating back to
3700 BCE. Although this papyrus does contain entries on surgical procedures as
well as the treatment of teeth, there is no mention of dental operations including the
extraction of teeth. Because there is an absence of evidence for surgical procedures
on teeth, the assumption has been made that dental extractions did not occur (Guerini
1909, p. 25). This papyrus contains 11 dental treatments and consists of plasters,
mouthwashes, masticatories, and incantations (Wynbrandt 1998, p. 12).
The Edwin Smith Papyrus dates from the same area and is considered to be the
oldest known surgical treatise, and it contains descriptions for the treatment of jaw
fractures. As dental forceps are found on stella and wall carvings, and Egyptians
suffered a variety of dental diseases, the assumption is that dental extractions did
occur during this era (Ring 1985, p. 35). In Additionally, Sir Marc Armand Ruffer
stated, “it is difficult to believe that extractions were not practiced at this time, but
the evidence is nil” (Leek 1967).
Rhazes (Abdu Bakr Muhammad ibn Zakariyyā al-Rāzī, 854–925 CE), a Persian
physician, described an interesting way of extracting a tooth – “extraction, a last
resort, is aided by first applying loosening agents such as arsenic paste or the juices
of a boiled frog” (Ring 1985, p. 35).
Albucasis (Abū al-Qāsim Khalaf ibn al-‘Abbās al-Zahrāwī al Ansari,
936–1013 CE), an Arab physician and surgeon, described a variety of dental instru-
ments and techniques to remove fractured teeth. He gave us one of the fundamental
precepts for performing extractions – “it is necessary first to ascertain which is the
aching tooth, as very often the pain deceives the patient, so that he may indicate as
to the very seat of the pain another tooth which is perfectly sound, and desires it to
be extracted; after a while, naturally, the pain does not cease…” (Garant 2013). Like
the Roman physician, Celsus, he also advocated filling the crown of a decayed tooth
before extraction to minimize the crushing of the crown during the extraction pro-
cedure (Ring 1985, p. 35).
The Chinese and Japanese cultures are both known for the non-instrument, finger
method of extracting teeth. In fact, practitioners in Japan were taught to extract teeth
by removing pegs pounded into a wooden board simply by using their fingers
(Bremner 1954, p. 341).

2.3 Greek and Roman Era

During the twelfth century BCE, the Greek physician and god of medicine
Æsculapius was recognized as the inventor of purgatives and the extraction of teeth
(Anonymous 1914, p. 21; Hussain and Kahn 2014). The model for the extraction
128 M. T. Goupil and V. Burke

Fig. 2 Lead odontogagon

found in the temple of
Apollo. (Image of the
public domain (Guerini
1909, p. 46))

forceps, the odontogagon (Fig. 2), was a pincer made of lead that was found in the
temple of Apollo and predates the temple of Æsculapius (Guerini 1909, p. 45).
Hippocrates and Aristotle wrote about dentistry including the extraction of teeth
in 500–300 BCE. Hippocrates’s description for extracting a tooth using the plumb-
erous odontogagon is said to be the first described dental operation (Ring
1985, p. 19).
Aristotle (384–322 BCE) described the application of the forceps (odontogagon)
in a passage from Mechanics. “It is formed by two levers…By means of this; it is
much easier to move the tooth, it is then easier to extract it with the hand than with
the instrument” (Wynbrandt 1998, p. 19, 20).
Like the Greeks, the Roman also performed dental extractions using the dentidu-
ceum which was based on the Greek odontogagon. In the first century, a Roman
dental patient could choose between a physician specializing in dentistry, a barber-­
surgeon, or a tooth-drawer to perform a dental extraction (Ring 1985, p. 41).
Aulus Cornelius Celsus (25 BCE–50 CE), a Roman encyclopedist, described in
his book series, De Medicina, tooth removal using a variety of botanicals to cause a
tooth to fall out. Celsus advocated packing the decayed cavity of the tooth with lint
or lead to prevent fracture of the tooth crown during extraction (Wynbrandt 1998,
p. 21). He further described the classical method for tooth removal used today – “the
gum must be detached all around, and then the tooth is shaken until it is loosened”
(Bremner 1954, p. 53).
This was further refined by Paul of Ægina, a seventh-century Roman physician:
“the extraction is begun by detaching the gum all around it as far as the alveolar
bone, then the tooth is seized with the forceps, shaken loose, and drawn out”
(Guerini 1909, p. 86).

2.4 Practitioners

The earliest “professional” recognized practitioners to extract teeth were university-­

trained physicians as evidenced by Hippocrates, Aristotle, Rhazes, and Albucasis.
Eventually, the physicians took a more of a hands-off approach to care and dele-
gated the extraction of teeth to barber-surgeons.
Evolution of Tooth Removal 129

The barber-surgeons were apprenticed trained for around five years. Their exis-
tence dates back to 1000 CE. Most physicians in Western Europe at that time were
members of the clergy. The papal edicts of the twelfth century prohibited members
of the clergy from letting blood, and thus, the barber-surgeons took on a greater role
in the extraction of teeth. Physicians that had also trained in surgery continued to
extract teeth (see Chap. 3 - Barber-­Surgeons).
One of the foremost recognized barber-surgeons was Ambroise Paré (1510–1590).
He underwent his apprenticeship in Paris and honed his skills as a military surgeon.
He was a prolific writer and inventor and made significant contributions to both
medicine and dentistry. His texts, Complete Works and Dix livres de la chirurgie,
contain illustrations of many of the dental instruments that he designed to extract
teeth (Guerini 1909, p. 18).
The third option that patients had for dental extractions was the tooth-drawer or
tooth-puller. These “practitioners” had little, if any, training. They were popular at
fairs as a type of entertainment. Their one skill was speed. Due to the lack of anes-
thesia, having an extraction was painful and the faster the better. The downside of
these rapid procedures was the potential for life-threatening complications, but by
that time, the tooth-puller had moved on to the next town (Ring 1985, p. 128, 132).

3 Early Instruments

The odontogagon, as noted above, is considered to be the prototype of the dental

forceps, and the basic design has not changed significantly to this day.
Giovanni d’Arcoli (1412–1484) described a number of tooth extraction instru-
ments in his commentary on the work of Arculanus. His invention of the “dental
pelican” was used into the eighteenth century for pulling teeth. Arcoli also advo-
cated the use of cautery to stop bleeding, a technique still practiced today (Fig. 3)
(Zampetti and Riva 2020).

Fig. 3 Pelican c.1650

(Bennion 1986)
130 M. T. Goupil and V. Burke

b
c
c
a

Fig. 4 Tooth key circa 1890 (courtesy of author MTG) and method of use (Hoffmann-­
Axthelm 1981a)

Walther Hermann Ryff (1500–1548), a German surgeon, was a prolific writer.

One of his texts contained a number of woodblock prints portraying dental instru-
ments, including forceps and elevators, that were in use at that time (Guerini 1909,
p. 166).
Pierre Fauchard (1678–1761), a French physician, is considered to be the “Father
of Modern Dentistry.” He gave specific instructions on the use of tooth extraction
instruments. He described separating the gum from the tooth, as previously advo-
cated by Celsus, loosening the tooth with an elevator, and placing the claw of the
pelican as far down on the root as possible. After loosening the tooth by “shaking”
it, next is completing the procedure with elevators, pincers, and fingers
(Atkinson 2002).
The tooth key dates back to circa 1740 and was based on a typical door key of the
period (Fig. 4). The bolster was placed against the tooth, and the hinged claw was
placed around the crown. The tooth was then removed by rapidly twisting the key
like turning a key in a lock (Kravetz 2003).
Albucasis provided the first drawings of extraction elevators in 1122. Elevators
in the eighteenth and seventeenth century had handles made of ivory or wood; they
were updated to stainless steel with the introduction of sterilization procedures
(Bussell and Graham 2008).

4 Nineteenth-Century Pioneers

For over a thousand years, little had changed in the methodology for the removal of
painful teeth. The tooth-pullers were sought out because their reputation for per-
forming an extraction rapidly meant less pain during the procedure. A major advance
in the evolution of tooth removal was the control of pain. Horace Wells, a keen
observer, noted that a person under the influence of nitrous oxide appeared to be
insensible to pain. He tested his theory by having one of his own teeth extracted in
December 1844 (Clark 1999).
Evolution of Tooth Removal 131

The anesthetic properties of cocaine were first described by the Spanish Jesuit
Bernabé Cobi (1582–1657) as treatment for toothache. But it was William Halsted
and Richard Hall that developed the technique of nerve block in 1885 that revolu-
tionized the practice of odontology (López-Valverde et al. 2011). One of the prob-
lems of the use of cocaine is its addictive properties. The German chemist Alfred
Einhorn overcame this addiction problem when he synthesized the aminoester, pro-
caine. He patented this local anesthetic under the trade name of “Novocain,” which
became the primary dental local anesthetic until it was supplanted by lidocaine and
mepivacaine in the twentieth century (Sheikh and Dua 2020). The removal of teeth
could now be conducted in a safe and comfortable environment.
The removal of teeth using forceps had remained relatively unchanged since the
twelfth-century odontogagon found in the Temple of Apollo. In 1826, Cyrus Fay, an
American dentist practicing in London, developed a new set of forceps. He designed
forceps that adapted to the cervical portion of the various human teeth (Bussell and
Graham 2008). Modern extraction techniques were further refined with the intro-
duction of the anatomical forceps designed, in 1840, by Tomes, an English dentist.
These were a set of instruments adaptable to the various shapes of individual teeth
(Rounds and Rounds 1953, p. 23).
The title of Father of Oral Surgery has been attributed to Simon P. Hullihen
(1810–1857). Although perhaps more known for his jaw surgeries, Hullihen also
contributed to the evolution of tooth removal with his innovations in equipment
design. He also made dental extractions a part of his practice as noted in his article
“Odontalgia: Observations on Toothache” printed in the American Journal of Dental
Science (Hullihen 1839; Armbrecht 1937).

5 Twentieth-Century Notables

The twentieth century was led off by the first text totally dedicated to the removal of
teeth, Exodontia, published in 1913, by George B. Winter. At that time, he coined
the terms “exodontia” and “exodontist.” In 1926, Winter published the definitive
text on the removal of a single tooth, the Impacted Third Molar, which provided one
of the commonly used classification systems still in use today (Rounds and Rounds
1953, p. 25).
The other well-known impacted third molar classification system currently in
use is the Pell and Gregory Classification System. This method was published in the
Dental Digest in 1933. Though other classification systems have been developed
over the past few decades, the Winter’s and Pell and Gregory Classification Systems
remain and are known worldwide (Pell and Gregory 1933).
For many centuries, teeth were removed primarily for the relief of pain and infec-
tion. Most techniques for tooth removal were still fraught with traumatic injuries
during the surgery. As indications for the removal of teeth changed, a less traumatic
means for tooth extraction was required. The use of the mallet and chisel was
described by Boyd Gardner, in 1911, for the removal of normally placed as well as
132 M. T. Goupil and V. Burke

mispositioned and impacted teeth. Gardner felt this technique was safe and effective
even in the hands of less experienced operators. The use of a mallet and chisel
allowed the removal of a tooth in its entirety with a minimal amount of trauma
(Gardner 1921).
The increase in the removal of impacted third molar teeth furthered necessitated
a safe and predictable surgical technique. Although the dental drill has a long his-
tory, many of the earliest surgical techniques were based on the use of the mallet and
chisel. In Pell and Gregory’s 1933 paper, they described the use of a chisel to split
the impacted third molar into several pieces depending on the angulation of the
tooth (Pell and Gregory 1933). This technique saw a resurgence during the Covid-19
era with the current concern about aerosolization caused by high-speed rotary
instruments. It is a useful technique to know for those practitioners providing care
in remote third world areas where resources are very limited.
Another method for impacted third molar removal using a chisel is the split bone
technique popularized in England. This method was introduced and taught by Sir
William Kelsey Fry and subsequently published by Terrence Ward in 1956. This
technique involves the removal of the mandibular lingual plate to deliver the
impacted tooth (Ward 1956).
Most oral surgeons utilize high-speed rotary instruments for the removal of bone
and the sectioning of teeth. One of the early proponents for the use of the dental drill
for removal of impacted teeth was Wilton Cogswell. His book Dental Oral Surgery
was published in 1932. In it, he described sectioning teeth into multiple pieces
based on the position of the impacted teeth when only a belt-driven engine and steel
burs were available (Nassimbene 2011). Cogswell’s descriptions of tooth sectioning
techniques still apply today. Through his extensive international lecturing and live
training with the use of over 200 wax models he had created, he influenced later
generations of surgeons in the techniques used by most surgeons today to extract
teeth. This includes our lead author (MTG), who subsequently taught this technique
like many others to their trainees.
Surgical techniques have been refined but are essentially the same as advocated
by Pell and Gregory and Cogswell. Improvements in radiographic imaging has
allowed improved assessment and risk/complication predictions. The techniques
and instrumentation have become more refined especially with the current goal of
replacing teeth with dental implants and the need to preserve bone.

6 Summary

The extraction of teeth is most likely the earliest surgical procedure performed by
humankind dating back to the Stone Age. Although performed primarily for the
relief of pain, extractions also contributed to aesthetics and cultural norms. Many of
the current surgical instruments utilized today have a fundamental design dating
back thousands of years. Prominent physicians and dentists over the years have
Evolution of Tooth Removal 133

refined the indications and techniques for the removal of teeth. This includes the
removal of impacted teeth including third molars. A review of history should always
be conducted before declaring something is “new.”

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Dental Implants and Bone Augmentation

Steven Halepas, Kenneth MacCormac, and Elie M. Ferneini

1 Introduction

Humans have waged a long battle against edentulism. Ancient history is poorly
documented in the scientific literature. A simple Google search supplies tales of the
earliest evidence of tooth replacement that is suspected to begin in 2000 BCE when
bamboo was carved into peg teeth and used as replacement in edentulous sites
(López-Píriz et al. 2019). A millennium later, a copper peg was hammered into the
upper jaw of an Egyptian king (Smith 2019). It is unknown, however, whether the
tooth was replaced during life or postmortem. In 500 BCE, Hippocrates wrote about
using artificial teeth bonded with gold or silk. Archaeological excavations in France
have uncovered a Celtic grave with a fake tooth composed of iron that is believed to
have originated from approximately 300 BCE (Smith 2019). Archeologists have
found many ancient civilizations with evidence of such tooth replacements made
from ivory, metals, and the teeth of other animals. Most scholars believe that these
replacements occurred postmortem as these implants would have likely had early

S. Halepas (*)
Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University
Irving Medical Center, New York, NY, USA
e-mail: [email protected]
K. MacCormac
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
E. M. Ferneini
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
Beau Visage Med Spa and Greater Waterbury OMS, Cheshire, CT, USA
Department of Surgery, Frank H Netter MD School of Medicine, Quinnipiac University,
North Haven, CT, USA

© The Author(s), under exclusive license to Springer Nature 135

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_10
136 S. Halepas et al.

failure. In the first century CE, Aulus Cornelius Celsus mentioned the possibility of
replacing missing teeth with cadaver teeth. The collections of the Peabody Museum
of Archaeology and Ethnology at Harvard University include a Mayan mandible
dated to the seventh to eighth CE in which three shell pieces were used as lower
incisor replacements (Pasqualini and Pasqualini 2009; Bobbio 1972).
The earliest evidence of attempted bone repair with a foreign material comes
from the Neolithic period between 10,000 and 4500 BCE. The skull of an ancient
Peruvian tribal chief was discovered with a large frontal bone defect that was
repaired with an implanted hammered gold plate (Pryor et al. 2009). While this may
seem quite primitive by modern standards, the Neolithic period is known widely for
the development of metallurgy and directly preceded the Bronze and Iron ages, so
this approach would have represented the absolute forefront of medical technology
(Lubbock 1865).
Jumping forward to 2000 BCE, we see the first example of a xenograft from
the ancient Khurtis people that inhabited modern Armenia. The anthropologist
A. Jagharian, former head of operative surgery at the Erivan Medical Institute in
Armenia, discovered two skulls with evidence of attempted grafting not far from
Lake Sevan (Pryor et al. 2009). One of the skulls showed a 7 mm traumatic injury
repaired with a single piece of animal bone. We can tell several millennia later
that the patient survived this procedure for several years afterward because the
cranium demonstrated signs of regrowth surrounding the grafted material (Pryor
et al. 2009). The second skull discovered by Jagharian demonstrated a similar
repair of a smaller 2.5 mm defect caused by a sharpened instrument (Pryor et al.
2009). Unfortunately, these finds predate reliable archival documentation by sev-
eral thousand years. Therefore, it is impossible to get a sense of whether these
procedures were commonplace or one-off experiments. Thankfully, much of the
early history of dental implants has been described elsewhere in the literature.
The authors implore you to explore the wonderful work of Ugo Pasqualini and
Marco Pasqualini entitled “Treatise of Dental Implant Dentistry: The Italian
Tribute to Modern Implantology (Pasqualini and Pasqualini 2009).” As an entire
textbook can and has been devoted to this subject, the authors herein will attempt
to highlight some of the monumental work that allowed for the development of
modern implantology.
Several centuries after the collapse of the Mayan civilization, many scholars dur-
ing the European Renaissance advocated for the splinting of lost teeth to adjacent
teeth using wire or thread. Pierre Fauchard, considered to be one of the founders of
dentistry, reported several cases of replantation and transplantation of teeth
(Pasqualini and Pasqualini 2009). The idea of replantation of natural teeth occurred
through the 1700s, until 1806 when Giuseppangelo Fonzi invented the first porce-
lain tooth (Anonymous 1968). Maggiolo then introduced the use of gold in the
shape of tooth roots, stating that it added stability when stabilizing to adjacent teeth
(Maggiolo 1809; Tanunja 2018). The use of metals for implantation into extraction
sockets became widespread during the nineteenth century. It is believed that in the
1840s, Chapin Harris and Horace Hayden, founders of the Baltimore College of
Dental Implants and Bone Augmentation 137

Dental Surgery, attempted implants with lead-coated platinum posts into artificial
sockets. Others in the United States tried different metals including lead, gold, sil-
ver, platinum, and nickel (Pasqualini and Pasqualini 2009).

2 Implants in the Early Twentieth Century

The central focus of this chapter is the beginning of the twentieth century, during
which procedures that resemble the modern implant began to emerge. Advancements
in implantology during this period primarily occurred through two avenues. The
first was new understanding in dental and osseous materials, and the second was
biomechanical principles and the refinement of the implant shape. In 1913,
Greenfield developed an endosseous hollow-cylinder basket shape implant made of
iridium and gold soldering as artificial roots (Greenfield 2008; Block 2018a). He
presented the stepwise use of drills increasing diameters that is still practiced today.
These implants were used as a single tooth replacement. In the 1930s, Drs. Alvin
and Moses Strock were researching the Vitallium® orthopedic screw fixtures used
in hips. They used this metal to place a series of implants for teeth in animals and
humans at Harvard. Vitallium is a cobalt-chrome-molybdenum alloy (originally
manufactured by Howmedica Osteonics Corporation, now Stryker, Mathway, NJ)
that was fabricated into a threaded design and placed as an immediate implant. In
1938, Adams developed and patented a submergible threaded cylindrical implant
with a smooth gingival portion and healing abutment. The prosthetic used was a
ball-hitch design for an overdenture (Burch 1997). Many new designs were fabri-
cated at this time, many of which mirrored the typical wood screw with a helical
thread pattern. Implants were typically a solid screw or hollow basket design com-
posed of different alloy materials that result in a fibrous implant interface
(Linkow 1966).
Prior to the hypothesis of osseointegration, implants used a fibrous-osseous inte-
gration system, which at the time was believed to be the ideal circumstance for
stability of the prosthesis. It was not until the concept of osseointegration or direct
integration of the bone to the metal that changed this fundamental thinking. In 1924,
Zierold researched the reaction of different metals in dogs (Zierold 1924). Some of
his observations were “gold, aluminum, and stellite were readily tolerated by bone
and tended to be encapsulated with fibrous tissue; they were inert materials, unaf-
fected by the living cells and body fluids; (2) silver and lead were slightly less toler-
able to bone, but they easily underwent corrosion, and created a greater connective
tissue response; (3) zinc corroded easily and caused a slight connective tissue reac-
tion; (4) copper caused definite stimulation of bone, although it underwent slow
corrosion; (5) steel and iron definitely inhibited bone regeneration and steel readily
underwent corrosion (Rudy et al. 2008).” The search of the perfect biocompatible
material continued. In 1940, the concept of osseointegration, specifically titanium,
was first described by Bothe et al. in Great Britain (Bothe et al. 1940; Jokstad 2017).
138 S. Halepas et al.

Later, a researcher in the United States reaffirmed this proposition stating, “since
titanium adheres to bone, it may prove to be an ideal metal for prosthesis (Leventhal
1951).” In the same year, Dahl invented the subperiosteal implant design (Linkow
and Dorfman 1991).
Linkow reported on the blade implant in 1968 (Linkow 1966). Prior to this, verti-
cal post-type implants with spiral shafts, vents, and pins were primarily used as
anchors for prosthetic support. Linkow noted difficulties with knife-edge ridges in
terms of placement and resorption. This observation led to the idea of thin blades of
larger anterior-posterior length rather than diameter. These were preformed after
raising full-thickness flaps, exposing all the bone. High-speed drills were used to
create channels, and the blades were tapped into the final position. Blade implants
were used with some initial success. Linkow stated the blade implants formed a
fibro-osseous integration that he believed was like the periodontal ligament of teeth
from a histological perspective (Linkow and Rinaldi 1987).
In the mid-1970s, trans-osseous implants were used for overdentures in the ante-
rior mandible. Kent et al. reported on the use of a mandibular staple bone plate to
support a dental prosthesis through an extraoral incision in the submental parasym-
physis region from the late 1970s. The plate was made from a titanium alloy (6%
aluminum and 4% vanadium). They reported promising results in terms of stability
in 160 patients. Bosker and van Dijk subsequently reported on 368 patients who
underwent the procedure, 43 had reversible complications, and 1 had unilateral hyp-
esthesia (Bosker and van Dijk 1989). The disadvantages to this approach were the
extraoral incision, the need for general anesthesia, and less than ideal gingival
implant interface.
In 1978, the National Institutes of Health (NIH) held a Dental Implant Consensus
Conference in Boston, Massachusetts, with the Harvard Tooth Implant-Transplant
Research Unit at the School of Dental Medicine (Anonymous 1978). At this point,
thousands of patients had been treated with dental implants for years. While many
had been successful, many others had early failures and complications. The
American Dental Association (ADA) had developed an implant registry to establish
uniform case reports. The Food and Drug Administration (FDA) had begun to
implement standards, classifications, and limitations on medical devices including
implants. The panel described success as “functional service for five years in 75%
of the cases.” The subject criteria for success included “adequate function, absence
of discomfort, improved aesthetics, and improved emotional and psychological atti-
tude.” The conference reported statistics on subperiosteal, transosteal, blade, and
staple implants (Fig. 1). Ultimately, the conference identified the need for clinical
trials to determine the best protocols for dental implants.
Professor George Zarb in Toronto, Canada, recognized the need for the contin-
ued clinical research expressed in the 1978 NIH conference. Notably, titanium was
not even mentioned at this 1978 conference. In 1982, the first Toronto Osseointegration
Conference was held. It was the first opportunity for the most prominent prosth-
odontic and oral and maxillofacial surgery community in North America to come
and learn from the most prominent dental implant researchers in the world at the
time (Jokstad 2008). Among them was Dr. Brånemark and his research team.
Dental Implants and Bone Augmentation 139

Fig. 1 The X-ray controlling from 1976 to 1977 shows a subperiosteal implant (according to
Cherchéve) in the maxilla. Two implant tripods (according to Pruin) in the lower canine region and
two stabilized blade implants (according to Heinrich) in the molar region. (Image from Wikimedia
commons. Public domain image. Reproduced without alterations. https://commons.wikimedia.
org/w/index.php?search=blade+implants&title=Special:Search&go=Go&ns0=1&ns6=1&ns12=1
&ns14=1&ns100=1&ns106=1#/media/File:Panoramic_radiograph_of_historic_dental_implants.
jpg. This image is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported
license. https://creativecommons.org/licenses/by-­sa/3.0/deed.en. CC BY-SA 3.0)

3 Brånemark and the Foundations of Modern Implantology

The development of the dental implant relied heavily on the progression of various
businesses throughout the second half of the twentieth century. Many different com-
panies played important roles. While it would be too time-consuming to discuss the
history of every business in the industry, we would be remiss not to include the
contributions of Straumann and Nobel BioCare due to the contributions of Drs.
Brånemark and Straumann. Reinhard Straumann founded the research institute Dr.
Ing R. Straumann AG in Waldenburg, Germany, in 1954. In 1981, Professor
Brånemark and the Swedish company Bofors cofounded Nobelpharma which later
became Nobel Biocare in 1996.
It was not until 1982 that Per-Ingvar Brånemark, MD, PhD, introduced the tita-
nium osseointegration implant to North America (Fig. 2). Professor Brånemark was
a physician and anatomist in Sweden who discovered the concept of osseointegra-
tion in 1952 while studying blood flow in rabbit bone. He placed a titanium-housed
optical component to a rabbit’s leg which allowed him to study the bones microcir-
culation (Fig. 3) (Brånemark 1983). After the completion of the study, he found he
was unable to remove the device. He noted that titanium components can bond
irreversibly with bone. This resulted in a pivotal movement in his team’s work,
which quickly identified the value of titanium in this context.
Brånemark was not the first to propose that titanium was a suitable biomaterial
for implantation in bone. Biological researchers in dentistry and medicine, includ-
ing Beder, Ploger, Emneus, and Stenram, were some of Professor Brånemark’s
140 S. Halepas et al.

Fig. 2 Photograph of
Professor Brånemark in
June 2013. (Image from
Wikimedia commons.
Public domain image.
Reproduced without
alterations. https://
commons.wikimedia.org/
wiki/File:Branemark_
headshot2. This image is
licensed under the Creative
Commons Attribution-­
Share Alike 3.0 Unported
license. https://
creativecommons.org/
licenses/by-­sa/3.0/deed.en.
CC BY-SA 3.0)

Fig. 3 Radiograph of Per-Ingvar Brånemark’s rabbit specimen, showing a titanium optic chamber
fixed to the rabbit’s tibia and fibula. (Image from Wikimedia commons. Public domain image.
Reproduced without alterations. https://upload.wikimedia.org/wikipedia/commons/4/47/
Branemark%27s_initial_radiograph.jpg. This image is licensed under the Creative Commons
Attribution-Share Alike 3.0 Unported license. https://creativecommons.org/licenses/by-­sa/3.0/
deed.en. CC BY-SA 3.0)

early mentors who demonstrated that bone tolerated implanted titanium well
(Emneus and Stenram 1960; Beder and Ploger 1959). “A simple search for titanium
on PubMed generates some 350 papers published before December 31, 1970
(Jokstad 2017).” But while his background was in orthopedics and anatomy, he saw
the immense opportunity in dental implants. His group extracted teeth in dogs and
replaced them by screw-shaped titanium implants. The implants were allowed to
Dental Implants and Bone Augmentation 141

heal under a mucoperiosteal flap. Fixed prosthesis was connected after 3 to 4 months
without loading. Radiological and histological analyses of the anchoring tissues
showed integration at 10 years (Brånemark 1983). In 1977, Brånemark et al.
reported on the osseointegration system for clinical jaw reconstruction using
titanium-­based implants (Brånemark et al. 1977). In 1983, they published a 5- to
9-year success rate of 3000 osteointegrated implants inserted into edentulous jaws
of 400 consecutive patients in Gothenburg, Sweden (Brånemark et al. 1983). Two
revelations were noted at this time. The first is the concept of osseointegration
between the implant and the bone. The second was the establishment of a biological
seal around the abutments penetrating the soft tissue, thus decreasing the inflamma-
tory reaction. In 1974, Straumann engineered the first titanium hollow cylinder
implant (Sutter et al. 1983). In 1997, NobelReplace released the first tapered dental
implant designs, a design that better mimics tooth root morphology.
Brånemark quickly understood the issue with successive bone loss over time as
well as the issue of inadequate bone for implant placement. In 1984, he and his col-
leagues reported on osseointegrated implants penetrating the maxillary sinus. They
first conducted an experimental study in dogs and later a clinical study in humans.
A total of 139 implants were placed that pierced the sinus or nasal cavity in 101
patients. At 5- to 10-year follow-up, the success rate was 70% in sinus-penetrating
implants and 72% in nasal bone/mucosa implants (Brånemark et al. 1984). In 1988,
Smalley et al. with the aid of Brånemark published on osseointegrated titanium
implants in the maxilla, zygomatic, frontal, and occipital bones for maxillofacial
protraction in Macaca nemestrina monkeys (Smalley et al. 1988). While this was
monumental in the world of orthodontics in terms of eliciting skeletal changes, it
was also the foundation for zygomatic implants in dental rehabilitation in the atro-
phic maxilla. The 1990s saw the use of maxillofacial implants for various recon-
structions of the skeletal complex after trauma or ablative therapy.
Many important advancements occurred in the 1990s that allowed for further
work with zygomatic implants. In 1995, Brånemark et al. described 156 edentulous
patients who were fully rehabilitated by fixed prosthesis with either four or six tita-
nium implants. After 3–4 months in the mandible and 5–8 months in the maxilla,
abutments were placed, and prostheses were fabricated. This landmark study was
the cornerstone for modern full-arch dental rehabilitation concepts we use today
(Brånemark et al. 1995). Two years later, Tarnow et al. reported on immediate load-
ing of threaded implants in 10 patients. Of 69 implants that were loaded, 67 inte-
grated. Six patients were treated with Nobel Biocare implants, one with ITI Bonefit,
two with Astra Tech TiOblast implants, and one with 3i implants (Tarnow et al.
1997). This was groundbreaking evidence as up until this point, Adell and Brånemark
had maintained that a prerequisite for successful osseointegration was a non-loaded
environment. The ITI® (International Team for Implantology by Straumann)
released the SLA (sandblasted, large grit, acid-etched) surface implant in June 1998,
increasing our understanding of osseointegration and implant success (Scacchi
et al. 2000).
In the search for a suitable esthetic fixed prostheses supported by dental implants,
Fortin et al. described the Marius bridge in 2002 (Fortin et al. 2002). The Marius
142 S. Halepas et al.

bridge was named after the first patient treated with this prosthesis. The implants
were placed between 1991 and 1994, and the bridge restorations were placed in
patients between 1993 and 1995 and followed for a period of 5 years. The process
required utilization of the concept of anterior-posterior spread, a fundamental prin-
ciple in 2020. The authors noted that moderate to severely resorbed maxilla often
have too thin of bone to allow vertical placement of implants, specifically in the
posterior region. The authors used tilted implants to overcome this obstacle. It is a
principle that will be carried forward over the next two decades. The “All-on-Four”
concept was first learned in 1998 with Maló, Rangert, and Nobre in collaboration
with Nobel Biocare. In 2003, Maló et al. described in the literature the use of the
“All-on-Four” immediate function with the Brånemark System for complete eden-
tulous maxillae with a 1-year follow-up in 32 patients. They used both straight and
angulated (17° and 30°) implants with Brånemark System multiunit abutments.
Immediate provisional complete arch acrylic prostheses were delivered the day of
the surgery, and a final prosthetic was delivered at 12 months postoperatively (Maló
et al. 2003).
Armed with information about immediate loading and anterior-posterior spread,
tremendous advancements in zygomatic implants for dental rehabilitation were pos-
sible. Prior to this, implants in the maxillofacial complex were targeted for recon-
struction of the skeletal structure rather than dental function. In 2000, Tamura et al.
published a case report of zygomatic implants following subtotal maxillectomy
with fabrication of a maxillary prosthesis (Tamura et al. 2000). In 2004, Brånemark
et al. published on 52 zygomatic fixtures for the atrophic maxilla with an overall
prosthetic rehabilitation rate of 96% after at least 5 years of function (Brånemark
et al. 2004). Two years later, Anlgren et al. reported on 25 successful zygomatic
implants placed from 199 to 2001, with an 11- to 49-month follow-up (Ahlgren
et al. 2006). That same year, Bedrossian et al. described the immediate function
with the zygomatic implants in 14 patients (28 bilateral zygomatic implants and 55
premaxillary implants) that supported an immediate fixed provisional prosthesis
(Bedrossian et al. 2006).
The desire for flapless surgery and immediate loading accelerated the develop-
ment of computer-aided treatment planning and fabrication of surgical stents and
prosthesis. In 2005, NobelGuide was released by Nobel Biocare as one of the first
guided surgery systems (Marchack 2005). In 2007, Bedrossian published a report
on the use of NobelGuide for a computer-guided, implant-supported complete max-
illary rehabilitation (Bedrossian 2007).

4 Bone Augmentation

The modern era of bone grafting began in the mid-seventeenth century with a Dutch
surgeon named Job Van Meekeren. In 1668, Van Meekeren performed the first het-
erologous grafting procedure on an injured soldier (de Boer 1988). He used a frag-
ment of dog bone to repair a skull puncture wound, and the procedure was successful
Dental Implants and Bone Augmentation 143

overall (de Boer 1988). However, in the eyes of the Christian church at that time, the
implantation of nonhuman tissues was considered blasphemous and resulted in the
excommunication of the soldier from the church. After enduring the unfortunate
consequences of excommunication from the permanent institution of the church,
the soldier returned to Van Meekeren to have the dog bone fragment removed so he
could be readmitted to the church. Unfortunately for the soldier, upon reentering the
site of the graft, Van Meekeren discovered that the fragment had completely incor-
porated into the surrounding tissues (de Boer 1988).
In the late seventeenth and early eighteenth centuries, orthopedic surgeons began
to focus their research efforts on the microscopic structure of bone aided by advances
in microscope technology. The earliest of descriptions of the microscopic anatomy
of bone came from Antonie van Leeuwenhoek. In 1674, van Leeuwenhoek pub-
lished the first description of the canal-based structure of cancellous bone and also
began to define the terms “implant,” “resorption,” and “bone callus” (de Boer 1988).
This foundational work opened the door for later research advances in bone physiol-
ogy and grafting. The discoveries and descriptions provided by van Leeuwenhoek’s
publications started an era of intense debate over the origins of osteogenic potential
in bone. In 1739, Henri-Louis Duhamel performed an animal experiment in which
he implanted silver wires beneath the periosteum and allowed the surgical wound to
heal for several weeks before reentering the site (Hernigou 2015). When he observed
the wires several weeks later, he discovered that they had become buried in bone
(Hernigou 2015). Duhamel used these experimental results and repeated the experi-
ments of some of his predecessors to validate his assertion that the periosteum had
osteogenic potential (Hernigou 2015).
Duhamel’s publications were met with mixed reception by his contemporaries.
His biggest opponent, Albrecht Von Haller, believed instead that the periosteum was
merely a support system for the blood vessels and that exudation from blood vessels
was the true cause of osteogenesis (Hernigou 2015). In 1763, Von Haller published
his book Experimentorum de Ossium Formatione in which he elaborated on the idea
that blood vessels carried the mineral elements required for osteogenesis and there-
fore were the major source of osteogenic potential. At the time, this was an extremely
controversial notion. The feud between the two men, who represented the two lead-
ing theories of the era, became notorious enough that it came to be known as
“Duhamel-Haller Controversy” (Hernigou 2015). Unfortunately, neither of the two
men would live to see the dispute settled. Jean Pierre Marie Flourens went a long
way in settling this controversy when he conclusively showed in his 1842 publica-
tion that periosteum was osteogenic and was the chief agent in healing and repair of
bone defects (Hernigou 2015).
Surgeons did not stand idle awaiting the resolution of academic conflicts and
chose to forge ahead with experimental procedures. In 1820, the German surgeon
Phillips Von Walters described the first use of a bone autograph (Henkel et al. 2013).
Walters successfully repaired trepanation holes – created during a procedure to
relieve intracranial pressure – with pieces of bone harvested from other sites on the
patient’s skull (Henkel et al. 2013).
144 S. Halepas et al.

Advances in both bone biology and bone grafting technology in the mid-­
nineteenth century were dominated by Louis Léopold Ollier. Ollier was a French
surgeon who began his career as a botanist and closely studied the microscopic
organization of tree bark, which perhaps sparked his eventual interest in periosteum
(Donati et al. 2007). In 1858, Ollier took the first scientific experimental approach
to solve the riddle of osteogenesis. Despite a lack of sterile surgical technique or
modern histological tools, Ollier made several discoveries and is credited with the
first use of the term “bone graft” in an 1861 publication (Donati et al. 2007). He
determined that transplanted bone and periosteum survived and became osteogenic
if given the proper conditions. In a textbook published in 1867, Ollier noted that
periosteum-coated grafts were best for transplanting and further stated that the con-
tents of the haversian canals and the endosteum were also osteogenic (Hernigou 2015).
These assertions were considered and incorporated into cutting-edge subperios-
teal and subcapsular surgical excision techniques, which became the standard of
care in the treatment of bony malunion secondary to traumatic fracture (Hernigou
2015). At this time, malunion was commonly treated with large resections or even
amputations. Therefore, the subperiosteal resection technique offered another
means to achieve bone healing and avoid amputation. These contributions earned
Ollier the Great Prize for Surgery established by Napoleon III. Despite being widely
considered an authority in the field by his colleagues and contemporaries, Ollier’s
publications were not without dissenters (Donati et al. 2007). In the late 1800s,
Arthur Barth, a German surgeon, began publishing the findings of his own experi-
ments in which he directly refuted the claim that the graft survived past the first few
days of implantation. Barth asserted that the implanted material underwent gradual
necrotic change (Henkel et al. 2013). He used rabbit and dog models to show that
dead graft material was resorbed and replaced by native tissues (Henkel et al. 2013).
This difference of opinions was one of the innumerable scientific feuds that would
not be resolved until after the time of both Ollier and Barth.
Around 1885, Ollier began to revisit some of his earlier experiments in xeno-
grafting. With the emergence of sterile surgical technique in the mid-1860s, he was
curious to see if new sterilization protocols would improve the outcomes of some of
his earlier failures (Hernigou 2015). Grafts were found to experience less morbidity
when the recipient [rabbit or cat] was from a higher species and the donor [chicken]
was a member of a less advanced species (Hernigou 2015). Ollier was also able to
successfully graft from one mammal to another; however, he noted that over time,
the graft material would disappear. He further noted that there was no guarantee of
a graft taking in a human recipient unless the donor material had come from a very
closely related species, such as monkeys, and even in that case, the graft only pro-
vided transient benefit (Hernigou 2015). With this in mind, Ollier concluded that
homographs and autographs were the most reliable options to repair bony defects
with the limitation of technology.
Despite focused research efforts from Ollier and his contemporaries, use of non-­
autologous grafts in human patients were seriously considered until late in the nine-
teenth century. The reason is not exactly clear; perhaps there were some religious or
moral concerns stemming from the experience of Van Meekeren a few centuries
Dental Implants and Bone Augmentation 145

earlier. In 1880, the Scottish surgeon William Macewen pushed the field into the
modern era when he published his case report from 1879, in which tibial bone from
one child infected with rickets was grafted into the heavily deformed humerus of
another child that had been resected secondary to osteomyelitis (Hernigou 2015).
This represented the first successful documented bone allograft in a human. The
achievement effectively opened up a new field in bone surgery. In the years that fol-
lowed this initial success, Macewen would earn further recognition by being the
first surgeon to repair a mandibular defect with bone harvested from the ribs (de
Boer 1988).
Abel M. Phelps was another important contributor to the early development of
bone grafting technology. In 1891, he published a landmark case report of a young
man with ununited leg fractures who has undergone several previous surgeries with
minimal success. Phelps was initially reluctant to continue attempting surgical
repair; however, sensing the desperation of the patient’s parents to avoid amputa-
tion, he agreed to try one last-resort measure (Hernigou 2015). Phelps transplanted
a portion of bone from the foreleg of a dog into the leg of his patient. Both donor
and host were left attached to each other for 2 weeks to maintain circulation to the
graft. Phelps believed that leaving the vascular supply of the graft intact would initi-
ate the growth of new bone in the boy’s limb (Hernigou 2015). About 15 days after
the graft, the patients were separated, and Phelps noted that the boy’s bone graft had
become irregularly covered in new bone. Both patients had a brief convalescence
after the operation (Hernigou 2015). Phelps claimed no specific references when
asked how he planned and designed the procedure. Instead, he said that “observa-
tion in my studies during the past two years convinced me that circulation between
two opposite species could be established with safety” (Hernigou 2015). While the
procedure was ultimately a failure, it still represents a landmark in the overall field
as it was the first example of a vascularized flap used in a human patient. Abel
Phelps’ meticulous documentation of his procedure, observations, and insightful
commentary on possible reasons for his failure allowed even his unsuccessful work
to become a stepping stone and invaluable training resource for the surgeons and
researchers that would follow.
The early twentieth century saw a new group of researchers such as Putti,
Phemister, and Albee rise to the forefront of bone grafting research and publication.
In 1912, Vittorio Putti, an Italian orthopedic surgeon, published a review of the
state-of-the-art research in the field of bone grafting and biology at the time. He
reviewed the work of previous authors, his contemporaries, and combined this
information with his own personal clinical experience and observations to elucidate
some generalized clinical indications for the use of bone grafts (Donati et al. 2007).
Putti also proposed a bone-lengthening technique, which is now called distraction
osteogenesis, and suggested novel uses of bone grafts such as grafting growth-plate
cartilage into adult patients (Donati et al. 2007). This report represented a unifica-
tion and clarification of many emerging principles of the era and formed the founda-
tion of much of the progress to follow.
In 1914, Dallas Burton Phemister performed several experiments in dogs to fur-
ther investigate osteogenesis. Earlier works had heavily debated the osteogenic
146 S. Halepas et al.

potential of the graft itself. There was ongoing disagreement about whether grafts
integrated via osteogenesis or if the existing donor tissue was responsible for inte-
gration (Donati et al. 2007). Phemister took a big step in introducing the modern
concept of bone resorption when he described a phenomenon he called “creeping
substitution” (Donati et al. 2007). He went further to say that the amount of time a
graft needed to complete its resorption was anywhere from 3 to 12 months depend-
ing on the size, thickness, and location of the graft (Donati et al. 2007). He explained
how the proximity of the endosteum and periosteum to adequate blood supply
would allow those tissues to survive, while the relative lack of circulation of the
deeper portions of the graft would cause cellular necrosis and resorption of the inor-
ganic portion of the cellular matrix (Hernigou 2015). Phemister’s 1914 publication
would become one of the most frequently cited English works in the field. This
authoritative publication was followed by an almost equally important work from
FH Albee. Albee published his “Rules for Using Bone Grafts” in 1915 which
described data from his own surgeries on various autologous bone harvesting sites
such as the iliac crest, trochanter, tibia, metatarsal, olecranon, fibula, and cranium
(Albee 1923).
By the mid-1940s, autologous and homologous bone grafting had become widely
used procedures. Alberto Inclan published an article in the Journal of Bone and
Joint Surgery in 1942 in which he presented the outcomes of a large number of his
cases and discussed the common issues of the current technology (Inclan 1942). At
that time, medical science was beginning to understand the immunological chal-
lenges related to homologous grafts. Inclan discussed that a homologous graft
between two living patients of the same blood group was possible, albeit inconve-
nient at times. He and his colleagues began to hint at the modern concept of storing
bone material for future use (Donati et al. 2007). In his 1942 publication, Inclan
began to outline a storage protocol for bone grafts. He wrote that grafts should be
kept immersed in the donor or host’s blood within a sterile glass container in a
refrigerated environment between 2 and 5 °C (Donati et al. 2007). While the imple-
mentation of the modern bone bank would have to wait for improved refrigeration
technology, the idea of uncoupling the harvesting and use of bone grafts was revo-
lutionary for the time (Donati et al. 2007).
While many of the brightest and most influential minds of the scientific commu-
nity were trying to define the best way to perform bone grafts using human tissues,
an equally dedicated group was beginning to research alternative materials to
replace bone. As early as 1892, Dressman was exploring the use of calcium sulfate
(plaster of Paris) for the repair of large bony defects (Donati et al. 2007). In his 1912
publication, Putti also commented on the use of ivory as a possible bone substitute
when harvesting adequate material from the donor or the host was not possible
(Donati et al. 2007). However, many early bone substitutes at this time led to the
same unfortunate outcome: infection, graft rejection, and, ultimately, failure of the
procedure. Medical science would need to make several key advances before mate-
rials could be designed to avoid some of the pitfalls of their earlier predecessors.
Calcium orthophosphates were discovered and described as early as the 1770s.
However, the use of materials such as hydroxyapatite (HA) in bone grafting studies
Dental Implants and Bone Augmentation 147

only began to gain momentum in the 1950s (Kattimani et al. 2016). HA has proper-
ties that make it nonreactive with the adjacent living tissues. For that reason, it
remains one of the more popular materials that accounts for a large quantity of the
regenerative graft materials available today (Kattimani et al. 2016). HA-based graft-
ing materials were truly revolutionary for the field of bone grafting overall. These
materials gave rise to what would later be called the first generation of biomaterials
(Hench and Thompson 2010). Professor Bill Bonfield, a medical materials researcher
at Cambridge University, was one of the pioneers whose research efforts led to the
widespread incorporation of bioactivity as a consideration in the design of new
materials and allowed the acceleration of the field from the 1960s forward (Hench
and Thompson 2010). During the 1960s and 1970s, the primary goal in the develop-
ment of new grafting materials was to diminish the biological response to the for-
eign body (Hench and Thompson 2010). This was achieved by eliminating release
of toxic by-products. These materials are called “bioinert” as they create no response
in the surrounding tissues (Hench and Thompson 2010).
Despite the success of the first generation of biomaterials and the improvements
they provided in the lives of millions of patients, Bonfield recognized the need for
an improved generation of biomaterials. The 1980s saw the rise of the second-­
generation biomaterials, such as Hapex, a material trademarked by Bonfield’s
research laboratory (Hench and Thompson 2010). Second-generation biomaterials
were designed to incorporate the concept of bioactivity, which aimed not only to
closely mirror the architecture of native tissues and their mechanical properties but
also to create a beneficial response in the tissues surrounding the graft (Hench and
Thompson 2010). These innovative materials were composed of polymeric matrices
of polyethylene with HA particles dispersed throughout. Bonfield continued design-
ing and discovering new biomaterials, such as Si-substituted HA, which is still con-
sidered a successful bone grafting material (Hench and Thompson 2010). By the
mid-1980s, bioactive bone grafting had reached clinical use in a variety of orthope-
dic and dental applications, largely thanks to the research and commercialization
efforts of the Bonfield laboratory.
Second-generation biomaterials explored the utility of bioactivity and materials
that were reliably and predictably resorbed by the host. These advances converged
in the third generation of biomaterials starting in the 2000s (Hench and Thompson
2010). Now, resorbable polymer systems are being modified on the molecular level
to elicit specific interactions with cellular integrins and thereby encouraging cellular
differentiation and extracellular matrix production and organization (Hench and
Thompson 2010). These materials generally fit into one of two categories: bioactive
glass or hierarchical porous foams that activate genes in neighboring tissues and
stimulate regeneration of living tissues (Hench and Thompson 2010).
The future of bone grafting materials is likely to be governed by two competing
schools of thought. In one camp, there are materials designed for in situ tissue
regeneration, and in the other, there is tissue engineering. The emerging field of tis-
sue engineering aims to seed progenitor cells on molecularly modified scaffolds
outside the body to allow the cells to become differentiated and mimic native tis-
sues. Engineered tissues are then implanted to replace diseased or damaged tissues.
148 S. Halepas et al.

By contrast, in situ tissue regeneration materials aim to achieve the same result by
implanting a material initially that will encourage the local tissue to regenerate or
repair itself. The addition of these concepts to improving knowledge of immunol-
ogy and endocrinology will lead to the emergence of new materials with multifac-
eted effects on regeneration and repair of local tissues.

5 Guided Bone Regeneration

Guided bone regeneration (GBR) procedures are dental surgical procedures which
use a membrane to guide the growth of bone and gingival tissues in areas that may
be lacking tissue for a variety of reasons. At present time, GBR is the intersection
of bone grafting technology with clinical dentistry. The rising popularity of dental
implants has driven interest in both the preservation and creation of bone as means
of developing sites for later prostheses. In 1976, Dr. Tony Melcher began defining
the basic principles and theories of GBR for use in dental applications (Melcher
1976). One of Melcher’s largest contributions was his recognition of the impor-
tance of using implantable barriers to exclude unwanted cell lineages from prema-
turely colonizing graft material (Melcher 1976). The positive results of Melcher’s
studies up to the 1980s and their application to periodontics sparked interest in the
study of rebuilding larger alveolar bone defects with guided bone regeneration.
GBR was first attempted by Dahlin et al. in 1988 on rats. They found that if the
bone was protected and kept away from adjacent tissues, via a membrane, there was
improved ingrowth of bone-forming cells into a bony defect; this was confirmed in
a study by Kostopoulos and Karring in 1994 (Kostopoulos and Karring 1994).
Recent systematic review has shown that the outcomes following GTR are highly
variable, both between and within studies, meaning that clinicians must still take
great care in case selection to ensure the best possible outcomes (Needleman
et al. 2006).

6 Sinus Lifts

The maxillary sinuses sometimes are in the way of placing maxillary posterior
implants. The development of both dental implants and bone augmentation materi-
als has allowed this procedure to develop and evolve. The first lateral window or
direct sinus-lift procedure is credited to Dr. Hilt Tatum in 1973. Dr. Tatum graduated
from the Emory University Dental School in 1957. He performed the first sinus
graft in 1975 at Lee County Hospital in Opelika, Alabama. This was followed by
successful placement of two implants. As many are aware, the sinus membrane is
quite thin and easily damaged. Early on, the sinus elevation was done using inflat-
able catheters. Eventually, instruments were fabricated to better handle this delicate
tissue. Dr. Tatum was presenting his findings at the American Academy of Implant
Dental Implants and Bone Augmentation 149

Dentistry in the late 1970s, and Dr. Philip Boyne was in attendance. Dr. Boyne and
his colleague Dr. James would advance this technique and publish their methods in
1980 (Tatum Jr. 1986; Boyne and James 1980). Dr. Robert Summers is believed to
have described first the internal/indirect sinus lift for sinuses that needed to be lifted
less than 4 mm. This technique is accomplished by preforming the osteotomies with
drills just shy of the sinus floor and using osteotomes to tap up the sinus floor leav-
ing the membrane intact. Bone particulate graft is then placed to keep the sinus
elevated, and the dental implants can be placed (Summers 1998). The lateral win-
dow for direct sinus lift is an invasive approach and may be falling out of favor. Dr.
Block published a technique in 2019 describing a crestal window approach for
direct sinus elevation with successful outcomes (Block 2018b). While sinus lift will
likely always have some indications, with the use of smaller implants, this tech-
nique could become less utilized.

7 The Twenty-First Century

Recently, there has been a renewed interest in the use of platelet-rich plasma (PRP)
and platelet-rich fibrin (PRF). Marx first described the use of PRP and PRF in the
dental field in 1998, where he reported positive healing of the alveolar bone with its
use (Marx et al. 1998). PRP is a concentration of platelet and plasma proteins
derived from whole blood that is placed in a centrifuge to remove the red blood
cells. PRP is believed to work via the degranulation of the alpha granules in platelets
which contain several growth factors (Scully et al. 2018). PRP contains a variety of
growth factors/cytokines such as transforming growth factor beta (TGF -beta),
platelet-derived growth factor (PDGF), insulin-like growth factor (IGF), and epider-
mal growth factor (EGF).
A study performed using 72 dental implants in nine beagles dogs attempted to
analyze the bone remodeling using PRP and PRF. After 3-month follow-up, the
authors concluded that there was no increase in primary or secondary implant stabil-
ity, but they did see a biological improvement in the peri-implant bone volume and
structural integration (Huang et al. 2019). Although clinical effects have yet to be
established, a biological effect is being consistently observed. In one in vitro study,
in which roughened titanium dental implants were treated with PRP, the authors
found that the number of cells observed around the implant at day 5 was double that
of the non-PRP-coated implant (Lee et al. 2016). Research into the use of such bio-
logics to increase osseointegration and soft tissue healing will likely continue over
the next several decades. A randomized, split mouth design was conducted for eight
patients who needed bilateral widening of keratinized mucosa around dental
implants in the mandible. On one side of the mouth, a free gingival graft was placed,
while on the other, a PRF membrane was placed. The mean amount of keratinized
mucosa at the implant at the PRF-only site was 3.3 mm ± 0.9 and 3.8 mm ± 1.0 at
the free gingival graft site (Temmerman et al. 2018). Now that integration of the
implants is well established, the interest in dental implants have pivoted to longevity
150 S. Halepas et al.

and precision. Soft tissue appears to be a key component in implant longevity and
late failure.
One of the greatest advancements so far of the early twenty-first century was not
so much in the dental materials but in treatment planning. Much of this is due to
better data collection primarily from computer-aided technology such as cone beam
computed tomography (CBCT), intraoral scanners, and treatment planning software
allowing virtual planning and milling of surgical guides. The twentieth century had
emphasis on getting stability and integration of the implant. The twenty-first cen-
tury has been about placing the implants in the ideal location to allow for optimal
dental prosthetic rehabilitation. When CBCTs first became available, radiographic
stents with fiducial markers are needed to be used with the planning software that
made its utilization cumbersome and required significant time by the provider. With
the advancement of scanners and software, fiducial markers are no longer needed.
Many companies have created user-friendly planning software to design implant
treatment plans and seamlessly use 3D printing technology to make surgical stents.
The use of a well-designed surgical stent results in less than 2 mm crestal and apical
deviation and less than 5-degree angulation error (Block 2018a; Luebbers et al.
2008; Nijmeh et al. 2005; Ewers et al. 2005).
Dynamic navigation has become common practice in the operating room, espe-
cially in cancer ablative surgery, and in surgery with difficult access. Dynamic navi-
gation uses the data from CT scans and optical sensors to track in live time where
the surgeon’s instruments are in relation to the patient’s anatomical structures on the
computer, allowing for more precision in operative technique. Dynamic navigation
has found its way into the world of dental implants with companies such as X-Nav
Technologies®. These systems have many advantages including more precision
with smaller flap designs given the improved accuracy even with less surgical access.

8 Future Direction

The twentieth century revealed that titanium appears to be the metal most biocom-
patible with bone. The first two decades of the twenty-first century has seen refine-
ment of titanium to increase success rates as well as escalate accuracy of placement
and restorations. Sandblasting, acid etching, and other techniques to cause rough-
ened surfaces of the titanium have allowed more successful bone-implant interfaces
(Wennerberg et al. 2018). Companies like Straumann and Nobel Biocare are con-
tinuing to refine their implant systems. In 2020, it is well established that long-term
implant survival relies on adjacent healthy soft tissue. Nobel Biocare has released
the TiUltra, which has advanced the field from focusing strictly on the bone-implant
interface to also incorporate the soft tissue-implant interface (Karl and
Albrektsson 2017).
Dental Implants and Bone Augmentation 151

The future of tooth replacement is likely not in the world of implantology but in
regeneration. While full summarization of the current knowledge of tooth regenera-
tion is outside the scope of this chapter, the authors felt it was appropriate to address
the path that tooth replacement will likely take. Through the understanding of odon-
togenesis, tooth regeneration can be divided into scaffold-based and scaffold-­free
models (Bhanja and D’Souza 2016). In 2002, Young et al. used a poly L-lactide-­co-
glycolide scaffold using third molar tooth buds of pigs and were able to grow min-
eralized tooth structures in immunodeficient rat hosts (Young et al. 2002). This
scaffolding work continues by many researchers including Duailibi, Honda, and
Young with promising results (Young et al. 2005; Honda et al. 2005; Duailibi et al.
2004). The major drawback of the scaffold technique is the developed teeth are
often very small and the size and shape are difficult to control. In 2004, Ohazama
et al. developed a primordial tooth by recombination technique with a scaffold-free
design that successfully developed normal histology (Ohazama et al. 2004). Nakao
et al. in 2007 developed a novel 3D organ culture method in which they regenerated
a tooth germ in a renal capsule and later transplanted to the jaw (Nakao et al. 2007).
In 2009, Ikeda et al. used a similar 3D organ method and transplanted tooth germ
into the first upper molar region of mice. The tooth demonstrated correct structure,
including enamel, dentin, cementum, pulp, and periodontal ligament space, but the
tooth was smaller than the natural teeth (Ikeda et al. 2009). Many challenges still
exist in tooth regeneration, the first being an appropriate cell source and the second
induction of odontogenic potency. Human urine-induced pluripotent stem cells
(iPSCs) have been shown to possess odontogenic competence in the right microen-
vironment, but there is still a need for identification of a “tooth inducer (Li et al.
2019).” Whether it be full tooth regeneration or cell-biased repair, the future of tooth
replacement is likely not in the world of biomaterials but in molecular and cell
biology.

9 Summary

The search for the optimal way to replace missing teeth is still at large. The search
for the best biomaterial and shape for dental implants consumed much of the twen-
tieth century. Early metals allowed for fibrous-osseous stability, but it was not until
the understanding of osseointegration with titanium that dental implants became a
mainstay treatment. Work on bone grafting substances to regenerate bone has
allowed providers to place dental implants in atrophic mandibles. The first two
decades of the twenty-first century have seen refinement of titanium to increase suc-
cess rates, as well as increased accuracy of placement and restorations using tech-
nological advances such as cone beam computed tomography (CBCT) and intraoral
scanners. Treatment planning software has further advanced accuracy through
152 S. Halepas et al.

virtual planning and milling of surgical guides and the creation of dynamic naviga-
tion. While dental implants have come a long way, the future of tooth replacement
likely resides not in the world of biomaterials but in molecular and cell biology.

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Midface Trauma

Michael S. Forman, Joy X. Chen, Joel M. Friedman, and Shahid R. Aziz

1 Introduction

The earliest known text to reference the management of facial trauma is the Edwin
Smith Papyrus, a scroll of trauma cases from ancient Egypt, dating back to at least
1700 BCE and postulated to reference texts as late as 3000 BCE (van Middendorp
et al. 2010; Breasted 1930). The series of cases outlining surgical traumas described
multiple cases of facial fractures. Maxillofacial trauma cases in the text include
various facial lacerations, head injuries, and fractures of the nasal bone, maxilla,
zygoma, and mandible. Some of these early cases will be described in the relevant
sections of this chapter.
The midface serves a critical function in not only facial appearance but also by
providing vertical strength to the head through its many buttresses. Adequate repair
of midface fractures restores much of what makes up an individual’s self-image and
enables one to speak, eat, and function appropriately. Given its importance, it is no
surprise that early writings focus on repairs of midface injuries.
Outside of the papyrus, one of earliest, well-documented descriptions of the
management of facial fractures can also be traced to Hippocrates (460–375 BCE).
His translated work reads “If the teeth at the point of injury are displaced or loos-
ened, when the bone is adjusted fasten them to one another…preferably with gold

M. S. Forman (*) · J. M. Friedman

Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University
Irving Medical Center, New York, NY, USA
e-mail: [email protected]
J. X. Chen
Will Surgical Arts, Rockville, MD, USA
S. R. Aziz
Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine,
Newark, NJ, USA

© The Author(s), under exclusive license to Springer Nature 157

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_11
158 M. S. Forman et al.

wire, but, lacking that, with linen thread, till consolidation takes place” (Dingman
and Natvig 1964). Medical historians believe that based on how casually he
describes this technique, that the method of using wire or bandages to stabilize
facial fractures had been around for quite some time prior to Hippocrates’ writings.
Most well-documented “modern” principles and techniques developed for the
treatment of midface trauma date back to the early twentieth century (Table 1).
Commonly, many advances in medicine or surgery occurred through wars, where
horrific injuries and crude conditions consequently led to clinical innovations and
breakthroughs. Unfortunately, it was the midface that was exposed and a major

Table 1 A timeline of important breakthroughs related to the management of maxillofacial trauma

1823 Von Graefe describes an apparatus to immobilize a fracture of the upper jaw with a metal
bar fixed to the premolars and tied to a headband.
1840 Baudens uses circumferential wiring to immobilize an oblique fracture of mandible.
1844 Strohmeyer describes the reduction of depressed zygoma fractures using a 1-prong hook.
1847 Buck is credited with applying wire sutures directly to fractured bones for stabilization.
1866 Gunning reports on treatment of fracture of the lower jaw by interdental splints.
1880s Open reduction and internal fixation with metal plates.
1885 Roentgen develops radiographic imaging.
1898 Use of frontal sinus ablation for frontal sinus disease.
1901 Introduction of the Le Fort classification system of midface trauma.
1921 Lynch describes the frontoethmoidectomy procedure.
1936 Anderson develops external appliance and pin fixation for the management of edentulous
mandible fractures.
1938 Konrad Zuse develops the first electromechanical binary programmable computer.
1942 Penicillin (discovered by Alexander Fleming in 1928) is first used to treat infection.
1942 Adams introduces the technique of internal craniofacial suspension of the midface and
direct wiring of zygomatic fractures.
1942 John Atanasoff and Clifford Berry complete development of the first digital computer.
1943 Transantral reduction of late fractures of the orbit with fat.
1944 Converse and Smith describe a surgical approach for repairing orbital fractures,
autogenous bone grafts, and early surgery.
1955 Bergara and Itoiz describe the use of the frontal sinus osteoplastic flap.
1958 Goodale and Montgomery describe the ablative frontal sinus procedure.
1960s Luhr and Perren et al. introduce Vitallium compression plates.
1964 Mustardé and Dingman and Natvig describe open repair and transnasal wiring to address
the medial canthal tendon.
1970 May et al. report on the importance of nasofrontal ducts.
1970s Introduction of rigid fixation concepts and absolute immobility.
1972 Hounsfield develops the first clinical CT procedure.
1972 Michelet and Festal introduce osteosynthesis with miniplates.
1977 Claussen et al. report on computed tomography and craniofacial injuries.
1978 Donald and Bernstein describe the first cranialization procedure.
1978 Champy et al. introduce the monocortical miniplate tension band technique.
Midface Trauma 159

Table 1 (continued)
1983 Gentry et al. describe facial buttresses based on high-resolution CT analysis.
1985 Stanley and Nowack and later Gruss et al. report on reconstruction of facial buttresses in
the management of complex facial trauma.
1985 Gruss et al. and others describe the role of primary bone grafting in NOE fractures.
1985 Ewers and Härle report on bioabsorbable plates and screws in the management of
maxillofacial trauma.
1986 Levine et al. report on stratification of the management of frontal sinus fractures based
on injury.
1991 Markowitz et al. introduce a NOE classification system based on the medial canthal
tendon.
1991 Putterman advocates CT findings for stratification of surgery.
1993 Hosemann et al. describe endoscopy and observation in the management of nasofrontal
ducts and NOE fractures.
1994 Gleason et al. combine 3D computer-reconstructed neuro-images with a novel video
registration technique for virtual reality-based, image-guided neurosurgery.
1997 Saunders et al. report on the use of the endoscope for orbital floor fractures.
2013 Weathers et al. describe the conservative shift in frontal sinus fracture management.
Louis and Morlandt (2018)
Abbreviations: 3D 3-dimensional, CT computed tomographic, NOE naso-orbito-ethmoid

victim of trench warfare—where more protection was naturally provided to the

trunk and limbs. Thus many of the pioneers in plastic, oral, and maxillofacial sur-
gery with both medical and dental backgrounds were able to publish based on their
experiences in the Great War, World War II, or the Balkan war. Original surgical
pioneers such as Harold Delf Gillies, Varaztad Kazanjian, and Robert Ivy all faced
unchartered circumstances with terribly wounded soldiers during World War I. In
part, the formal field of plastic surgery emerged after the world wars with Harold
Gillies serving as the founder and first president of the British Association of Plastic
Surgery in 1946.
During the Great War, many multidisciplinary teams emerged to take care of
facial injuries since most doctors were not accustomed to treating the injuries that
presented from missiles, explosions, and bullets. As mentioned, Harold Gillies, a
New Zealand native, became widely recognized as one of the founders of facial and
plastic surgery. Much of this occurred at the Queen’s Hospital at Sidcup, Kent,
United Kingdom. To demonstrate the multiple collaborations that occurred, in many
of Gillies’ writings, he credits a dentist with whom he worked closely with for inspi-
ration, Charles Valadier. Valadier was a dentist originally born in Paris, but raised in
America. He volunteered via the British Red Cross Society to help out in the war in
1914. Gillies wrote, “The credit for establishing the first Plastic and Jaw Unit, which
so facilitated the later progress of plastic surgery, must go to…Charles Valadier”
(McAuley 1974). Historically speaking, it is described that much of the facial sur-
gery done during the wars were completed by a multidisciplinary team of providers
working together. Gillies met Valadier when he volunteered for the Red Cross in
1915 (Simpson and David 2004).
160 M. S. Forman et al.

It was Valadier in 1917 who was one of the first to outline the principles for the
management of facial trauma through his wartime experiences (Valadier and Whale
1917). He described a few key principles: (1) All remaining teeth should be pre-
served to provide support for interdental splints. He keenly notes that the secret to
effective repair was to obtain proper occlusion of teeth. Interestingly, he commented
an English soldier’s mouth was difficult to treat because their teeth were generally
“poor in quality and few in number” (Valadier and Whale 1917). (2) Wounds should
be closed as soon as possible. He sharply noticed that lacerated tissues retracted and
subsequently made closure difficult to impossible. At the same time he commented
that closure can also lead to scar formation and trismus and that tissue stents will be
required to maintain volume as the tissue contracts. (3) Ultimately, for the manage-
ment of facial bone fractures, he used a series of interdental positioning stents to
stabilize midface and jaw fractures with the addition of wire or suture fixation. He
fabricated a stent for each individual patient and each unique fracture pattern. The
goal was always the same—to stabilize and immobilize the segments of the bone
across the fracture lines. At times he utilized extraoral devices to help manipulate
the segments to their appropriate positions. A combination of tooth-borne fixation
devices and wiring allowed him to treat the plethora or midface trauma injuries he
encountered.
Lastly, for wound care and to prevent infection following stabilization of the
midface and closure of the soft tissues, he placed a drain into the wound. He devel-
oped an apparatus nicknamed by wartime patients, as the “Fire Engine” (Valadier
and Whale 1917). It was a device he travelled through the wards with, irrigating
wounds under pressure with boiled water to keep his surgical sites clean.
Most of the novel principles described during World War I and by Charles
Valadier are still in practice today and have led to incredible achievements in maxil-
lofacial surgery since that time. More information regarding their experiences dur-
ing the war can be found in the dedicated chapter on this topic. However, it is
important to understand the impact of the wars as a key period for advancing oral
and facial surgery. Dental professionals and, in particular, oral and maxillofacial
surgeons have always played a critical role in the management of these injuries. In
this chapter we will review the earliest documented procedures our research revealed
related to the maxilla, zygoma, and nasal bones. Remarkably, many guiding prin-
ciples have not changed significantly over the past 1000 or more years compared to
present-day standard of care.
Fortunately, several important advances in the management of maxillofacial
trauma in the last 40 years have resulted in improved outcomes. These include the
development of high-resolution computed tomography (CT), rigid fixation tech-
niques, improved biomaterials, soft tissue resuspension, and primary bone grafting.
Further advances in outcomes have occurred with the use of virtual surgical plan-
ning, endoscopic techniques, and surgical navigation.
Midface Trauma 161

2 Imaging

One of the most important advancements in medicine is the advent of modern imag-
ing techniques. Since the first use of radiographic imaging by Wilhelm Conrad
Roentgen in 1895, no significant changes in medical imaging occurred until the
advent of the computer. The computer allowed for more sophisticated imaging tech-
niques with greater diagnostic capability. In 1972, an engineer named Godfrey
Hounsfield performed groundbreaking research that led to the development of the
first clinical computer tomography (CT) scanner. He shared the Nobel Prize in
Medicine and Physiology in 1979 with Allen Gormack, a physicist, for the develop-
ment of computer tomography (Seeram 1994). In 1977, Claussen et al. reported the
first use of computed tomography in diagnosing craniofacial injuries which allowed
for unprecedented visualization and analysis of the complex anatomy associated
with craniomaxillofacial surgery (Claussen et al. 1977).
With advancements in CT technology, the modern clinician can evaluate cranio-
facial injuries and fracture patterns in great detail via individual cuts or 3D-rendered
reconstructions. Three-dimensional imaging paved the way for the development of
guided surgical navigation, virtual surgical planning, and patient-specific implants.

3  he Maxilla, Rene Le Fort, and Le Fort I, II,

T
and III Fractures

One of the earliest treatment methods for fractures of the maxilla dates back to
1832, when Karl Ferdinand von Graefe, a German surgeon, introduced an apparatus
for the treatment of maxillary fractures (Dingman and Natvig 1964). The device
utilized extra-skeletal fixation via use of a circumferential fronto-occipital band of
metals as an anchor with two adjustable vertical supports. The vertical supports
housed curved hooks to fit over the patient’s teeth for stabilization. This ultimately
immobilized the maxilla, using anterior teeth as a point of fixation to the forehead,
providing extra-skeletal fixation. Interestingly, similar methods utilized this creative
device well into the mid- twentieth century. In 1887, an American, Thomas Gilmer,
is credited with the development of intermaxillary fixation (IMF) via wiring and
described its use for the management of complex jaw fractures (Gilmer 1904).
Fractures of the maxilla are rarely encountered alone, but often in conjunction with
other facial bone fractures. Thus, while principles of maxillary fractures will be
introduced and explained here, relevant principles will be further expanded upon in
other sections of this chapter.
In 1901, Rene Le Fort, a French surgeon, completed a series of cadaveric experi-
ments that led to perhaps the most widely used and known fracture classification
162 M. S. Forman et al.

system in effect today. No midface history chapter would be complete without a

brief review of these novel and infamous experiments. He set to evaluate the manner
in which fractures propagated throughout the midface and questioned midface con-
tiguity with the skull base. He tested three main conditions: (1) the point of applica-
tion of the force, (2) the direction of the wounding agents, and (3) the position of the
head during the trauma (Tessier, 1972a). Le Fort utilized a variety of different
methods such as “administering a very violent blow with a wooden club” or “vio-
lently projecting the skull against the autopsy table” (Tessier 1972a). He deliber-
ately applied an array of forces to specific areas of the face (e.g., nose, malar bone,
or alveolus) with the head stationary, dangling off the autopsy table or being pro-
pelled itself. Through his findings, he described “great lines of weakness” which
later contributed to what we now call a Le Fort I, II, or III fracture.
The first great weak line—which he described as the protection barrier of the
cranial cavity—is the nasal septum and vomer. A second great weak line “circum-
scribes the whole middle part of the face, in which the malar bones are not involved”
which we understand today as a Le Fort II.
He observed that the maxilla, despite its anatomical connections to the skull
base, is physiologically independent from it (Tessier 1972a). He discovered there
are bony columns in place above the alveolar arch that are able to distribute the
natural vertical forces from the lower jaw over a very broad cranial area. Laterally
this includes the malar bones which distribute the forces into large areas of the max-
illa and skull base. He also identified certain weak points in this area which caused
facial bones to break in a manner preserving forces distributed to the brain. He
noticed that trauma involving the malar bones can cause the separation of the face
from the skull (Le Fort III). When describing this weak line, he wrote “this line
passes through the nasal bones…The upper part is very resistant. When it yields, the
cribriform plate of the ethmoid bone yields also. From the nasal bones the fracture
line runs toward the orbit” (Tessier 1972b).
Finally, he described a third weak line which cuts across the face—starting from
the lower part of the pyriform aperture; crossing the canine fossa, below the malar
bone; and meeting the second line (which ultimately rises posterior to cross the
pterygomaxillary fissure and cut the pterygoid process). This of course referred to
the most common type of fracture, a Le Fort I. These imaginative and ferocious
studies aid surgeons to this day in understanding the anatomy of common facial
fracture patterns.
The treatment principles of maxillary fractures and the described Le Fort I, II, or
III fractures are all based on the re-establishment of functional dental occlusion and
fragment immobilization. These principles were demonstrated with the extra-­
skeletal facial devices employed in the 1800s. Generally, the main methods devel-
oped to accomplish these primary objectives were intermaxillary fixation (IMF) and
either internal or external fixation. The first was considered a closed treatment
option commonly achieved with Erich arch bars, or an equivalent method, to re-­
establish occlusion and provide stabilization of the fractured segments. The
Midface Trauma 163

pressure of the mandible against the maxilla both reduces the fracture and stabilizes
it in place (Dingman and Natvig 1964). This principle is well understood today for
the management of the same fractures.
The alternatives to intraoral fixation alone were a form of external or internal
fixation as modern hardware did not get introduced until the 1970s. We will spend
some time reviewing the principles of such treatments here, which are germane to
the other sections of this chapter, that utilize the same techniques of external and
internal rigid fixation.
External fixation consisted of any method that immobilized the fractured maxilla
by utilizing a stable extraoral form of fixation to a point on either the mandible or
maxilla. One common method was cranio-maxillary rigid direct suspension that
was similar to Karl Ferdinand von Graefe’s headcap described earlier. This method
utilized a maxillary tooth-borne cast that connected via rods to a plaster of Paris
headwrap, immobilizing the fractured segment. Alternatively, a halo frame which
was described in the 1950s for cervical traction was applied to maxillofacial injuries
in the mid-1960s (Rowe and Kelly 1968). It was also commonplace to pass a
“cheek-wire” which was a trans-buccal wire connecting the halo frame to the max-
illa. The wire was passed through the soft tissues with a spinal needle. Cranio-­
mandibular fixation was a form of indirect support which stabilized the maxilla in
occlusion by way of mandibular immobilization. The mandible could be immobi-
lized in a similar fashion as just described.
Overall, early treatments all revolved around connecting the maxilla or mandible
via a tooth-borne splint in place to any extraoral rigid point of fixation (plaster of
Paris headframe, halo frame, or external skeletal pins) via metal rods or wires. There
were creative ways to do so, many of which were quite bulky and cumbersome.
Fortunately, these techniques quickly fell out of favor as more favorable treatment
options developed.
Prior to “plates and screws.” internal fixation consisted of either trans-osseous
wiring (e.g., wiring across the zygomatico-frontal suture), direct suspension (e.g.,
wiring from the maxillary arch bar to a point superior to the fracture line), indirect
support (e.g., wiring from the mandibular arch bar to a point superior to the fracture
line), direct support (e.g., use of packing), or trans-fixation (e.g., Kirschner wires or
Steinmann pins) (Dingman and Natvig 1964).
To accomplish internal wire fixation, the patient was placed into IMF. Second,
the wire fixation was between either the maxillary arch bar (direct) or mandibular
arch bar (indirect) and to a point superior to the fracture line, typically the infraor-
bital rim, lateral zygoma, or pyriform rims. An incision was made from the skin to
the bone at the selected site, with drill holes completed via use of a hand-turned
drill. A stainless steel wire was passed from the drill hole into the oral cavity, where
it was secured to the selected arch such as the maxilla (Dingman and Natvig 1964).
This allowed the maxilla to be positioned by occlusion with additional support by
the fixation wire. Le Fort II and III fractures were treated with the same principles,
with differing anchorage points depending where stable bone was. For Le Fort II
164 M. S. Forman et al.

fractures, wires were passed directly across the infraorbital area or from the zygo-
matic process of the frontal bone, referred to as “cranial suspension,” to the man-
dibular arch bar, with the patient in IMF. Edentulous patients of note had dentures
wired via suspension wires to the maxilla, superior to the fracture line, and then
placed into IMF. Interestingly, it was commonplace for the anterior teeth to be
removed from the denture for the patient to better accommodate eating and drinking
during the healing phase.

3.1 Modern Treatment

In the last 40 years, rigid fixation has become the mainstay treatment for midface
fractures. The concept of rigid fixation uses hardware in the form of bone plates and
screws to absorb part or all of the functional load of the fracture site, thereby pre-
venting any mobility of the fracture segments. The advent of rigid fixation started in
the early nineteenth century. In 1866, German surgeon Carl Hansmann was the first
to experiment with the plate and screw system on orthopedic fractures and was also
the first advocate of rigid plate fixation in maxillofacial injury (Verbeek 1955). In
the 1890s, Belgian surgeon Albin Lambotte was one of the first to publish on the
technique of internal fixation of displaced orthopedic fractures. Lambotte coined
the term “osteosynthesis” and outlined the tenets for the technique which includes
limiting dissection and preserving the periosteal covering to maintain the bone’s
blood supply. The first plates Lambotte used were designed and milled by him in his
private workshop. The initial design was a trapezoidal plate made of a copper alloy
with nickel and zinc. However, due to the high rates of complications such as infec-
tion, osteosynthesis of orthopedic fractures was put on hold for many years until
after the development of modern aseptic technique and the discovery of antibiotics
in the early twentieth century (Lambotte 1987).
Rigid fixation found favor in orthopedic literature in the mid-twentieth century
with a 1949 publication by Luhr who described compression of bony fragments as
an important adjunct to fracture healing (Luhr 1982). Subsequently in 1958, Bagby
and Janes published an article detailing the use of bone plates to achieve immobili-
zation of the fracture and active compression which showed more favorable clinical
outcome than closed reduction (Bagby and Janes 1958). Early literature on the
application of rigid fixation for craniomaxillofacial fractures showed mixed results
as most appliances available were designed for extremity fractures. In 1973, a land-
mark paper was published by Michelet et al. where they advocated for the use of
small, malleable Vitallium (cobalt-chromium alloy) plates and detailed 300 clinical
cases where miniaturized plates and screws were used in the reduction and immobi-
lization of maxillofacial fractures (Michelet et al. 1973). Since then, many different
systems and materials have been introduced and have evolved into the current sys-
tems we have today. The use of miniaturized plates (“miniplates”) and screws in
maxillofacial fractures is now considered the standard of care in the treatment of
maxillofacial injuries.
Midface Trauma 165

Current techniques in the management of midface fractures involve the use of

miniplate fixation, primarily along the facial buttresses for optimal stability and
maintenance of the midface vertical height. This concept evolved from the descrip-
tion of facial buttresses by Gentry et al. in 1983 and multiple publications by Gruss
et al. on the important role of facial buttresses in maxillofacial reconstruction
(Gentry et al. 1983; Gruss and Mackinnon 1986). Rigid fixation with miniplates in
the maxilla also allows for immediate function, forgoing of maxillomandibular fixa-
tion, and more predictable outcomes.
A split palatal fracture can occur in conjunction with other maxillary fractures
resulting in issues with the transverse width of the midface. Treatment of such split
palate fractures utilizes basic orthognathic surgery principles. Dental impressions of
both arches are taken, and model surgery is carried out to re-establish the original
occlusion. An occlusal splint is then made and wired to the maxillary dentition dur-
ing open reduction and internal fixation of the fracture to correct the transverse width.

4 Zygoma and Zygomatic Arch Fractures

The first description of a fracture to the zygoma is from the Edwin Smith Papyrus,
“If thou examines a man having a smash in his cheek…should it crepitate under thy
fingers, while he discharges blood from his nostril…” (Breasted 1930). While for
other injuries daily honey and lint applications are often recommended, for this
injury the writer determines it is, “an ailment not to be treated.”
As outlined previously, the historically established principal objectives of treat-
ing any fractures are to reduce the fragments in a way that restores form and func-
tion and to provide adequate support during the healing course. This was done via a
wide variety of treatment options for zygomatic fractures over the past hundreds
of years.
Dr. Guichard Du Verney, a French otologist, described what may have been the
first formal treatment methods of zygomatic fractures in the modern era (Smith and
Yanagisawa 1961). In his book published in 1751, he described three methods uti-
lizing intraoral digital pressure, mechanical occlusal or masticatory forces, and
external pressure. They are outlined as follows:
1. “I introduced my index finger of my left hand into the mouth of the patient and I
placed it over the first molar tooth, the more forward that I could [push] with the
finger within, outward and I realized that by the touch the zygomatic process was
fractured and depressed” (Smith and Yanagisawa 1961).
2. “I told the patient to take a piece of wood slightly flattened thick as a finger, and
put it over the last molar tooth and to close the mandible as much as he could.
After having done this for a few hours he felt pulling; he kept on doing it, increas-
ing the size of the size of wood and by this means the pieces came back into
place by the action of the contraction of the temporal muscle, that pulls the pro-
cess from inward outward” (Smith and Yanagisawa 1961).
166 M. S. Forman et al.

3. “I applied the palm of the hand over the cheek, pressing a little and the process
came into place” (Smith and Yanagisawa 1961).
Throughout the 1800s, with the advent of instruments, many novel methods were
described. Utilizing a variety of direct incisions or wounds, a number of imaginative
techniques were attempted. In 1878, Dr. David Agnew, an American surgeon from
Philadelphia, published a three-volume series on surgery. He recognized the chal-
lenge of restoring facial harmony with digital pressure alone and utilized a screw
elevator, functionally identical to the modern-day Carroll-Girard, to aid his reduc-
tion. He writes, “If there is displacement, it must be corrected by pressure applied
inside of the mouth or outside of the cheek…If the body of the bone is depressed,
which implies also a broken antrum, the screw elevator, bored into its substance,
will be the most convenient method of restoring it to the proper position” (Agnew
1878). I think it is also important to appreciate that in 1878, surgical principles such
as dependent drainage were already commonplace in practice—“When no wound is
present, in incision must be made…it should be carried along the lower rather than
along the upper margin of the zygomatic…although a few muscular fibers belong-
ing to the masseter must be cut, we shall have a dependent wound for the escape of
any collection of blood or pus” (Agnew 1878). He continues to advocate for wound
care and pain control following the reduction with “lotion of lead-water and lauda-
num” (Agnew 1878).
One of the next major treatment approaches was written by Dr. Howard Lothrop,
an American surgeon from Boston who was a Surgeon-in-Chief at Boston City
Hospital. He advocated for an antral route via the canine fossa, utilizing direct ele-
vator of the fragments from within the antrum by outward pressure (Dingman and
Natvig 1964; Smith and Yanagisawa 1961; Keen 1909). He approached this by mak-
ing, “a horizontal incision, about three quarters of an inch long…along the line of
the junction of the mucous membrane of the alveolus and the cheek…the director
should now be pushed through…into the antrum…then a 24 French sound is intro-
duced… gradual increase in pressure should now be exerted…” (Smith and
Yanagisawa 1961).
In 1909, Dr. William Williams Keen, an American surgeon, published three
methods of operating, including an intraoral technique for reduction, which is an
approach still commonly referred to today by his namesake. One method was a
direct method, “an incision is made through the skin and the fragments pulled out-
ward” (Keen 1909). However he commented that it was objectionable both due to
scar formation and poor outcomes. His second method was “through the mouth by
inserting blunt instruments beneath the bone from within and lifting the fragments
up” (Dingman and Natvig 1964; Keen 1909). Of note, he does not describe an intra-
oral incision here; however to this day an intraoral approach for this fracture is still
referred to by “Keen approach.” For his third method, he refers to the method of
Lothrop, which is described previously above.
In 1913, Dr. J.G. Manwaring, a surgeon from Flint, Michigan and a founder of
the American College of Surgeons, published the use of dental cow-horn forceps for
reduction of zygoma fractures in the Journal of American Medical Association
Midface Trauma 167

(Manwaring 1913). He writes “For elevating depressed fractures of the malar bone
I have used an instrument always obtainable, the ordinary ‘cow-horn’ forceps of the
dentist. One point of the forceps is placed over the orbital ridge and the other just
under the margin of the body of the bone...no dressing is necessary…the holes in the
skin are mere pricks” (Manwaring 1913). Understanding obvious skepticism he
continues, “This is more readily appreciated when tried, than would be
believed…[provides] sure control it leaves no scars, is quickly used, and does not
enter through the mouth cavity” (Manwaring 1913).
In 1927, a novel temporal approach was described by Gillies, which is another
technique that is still commonly practiced today and referred to by his namesake
like the Keen intraoral approach (Figs. 1 and 2). Gillies writes, “Our technique…dif-
fers from those mentioned. A curved incision, 1.5 in. long, is made over the
temporal muscle…an incision is made in the temporal fascia; and a long, thin

Fig. 1 Gillies zygoma

elevator, designed for the
temporal “Gillies”
approach to zygomatic
arch fractures

Fig. 2 Surgical
photograph demonstrating
the temporal “Gillies”
approach and operative use
of the Gillies zygoma
elevator
168 M. S. Forman et al.

elevator is passed downwards on the surface of the temporal muscle until it lies deep
to the displaced bone” (Gilles et al. 1927). The advantages of this technique that are
well known today were self-evident at that time as well: hidden scar location, safe
dissection plane, and adequate leverage to reduce the fracture segments. In the same
paper of note, the authors outline the importance of a “supero-inferior view of the
skull” and technique for the radiograph to highlight and isolate the arch post repair
(Gilles et al. 1927). This landmark publication has survived the standard of care for
nearly a century.
In 1928, Dr. Sam Roberts described using a corkscrew instrument similar to
Agnew’s use of a screw elevator in 1878 for reduction (Roberts 1928). “A stab is
made…about three-fourths of an inch directly below the external canthus… The
screw is then inserted, with a half turned motion in a perpendicular plane with the
flat surface of the bone. Considerable pressure may be necessary in older patients to
penetrate the bone…as soon as one full turn of the screw has passed through the flat
bone, it may be elevated to a normal position” (Roberts 1928).
Over the next few decades, multiple variations on the previously described meth-
ods were attempted. Various instruments, wires, and approaches were all used to
reduce and stabilize the segments that only varied slightly. In 1931 a novel anatomi-
cal approach was introduced—A nasoantral route was proposed by making a win-
dow under the inferior turbinate and inserting a curved sound (Smith and Yanagisawa
1961). Kazanjian and others propose variations on plaster of Paris headcaps or a
halo frame as described for Le Fort fractures, to which a screw or wire attached to
the zygoma was fixed to, thus stabilizing the reduced segments (Dingman and
Natvig 1964; Smith and Yanagisawa 1961; Kazanjian 1927; Flynn et al. 1958).
In the 1940s, internal rigid fixation via wires and pins began to be described. In
1946, a technique was introduced that was internal wire-pin rigid fixation for
zygoma fractures (Brown 1946). After reduction, stainless steel pins were driven
through the skin and zygoma in a transverse direction into solid parts of the maxilla
or zygoma on the contralateral side (Brown 1946). They were removed at 4–6 weeks
following an adequate or uncomplicated healing process.
However it was Dr. William Milton Adams from Tennessee in 1943 that made a
major breakthrough and published one of the earliest reports on open reduction and
internal wire fixation as a form of rigid fixation independent from external support
(e.g., plaster headcaps) (Adams 1943). He acknowledged the limitations of all of the
many treatments described above in this chapter and believed that his internal wire
fixation “meets the requirements of facility of operation, complete immobilization,
sound surgical principles, and is applicable to practically every type of fracture of
the facial bones” (Adams 1943). With the benefit of time now, we can appreciate
the genius and accuracy of his intuition. The benefits were obvious—since complete
immobilization was achieved—repeated adjustments were unnecessary, and patients
would not have to deal with bulky, complex extraoral appliances. The headwraps
used as anchors for immobilization were imperfect, time-consuming, and required
Midface Trauma 169

continual adjustments. Even in 1943, however, the importance of a large armamen-

tarium was well understood by pioneers in facial surgery. Adams understood that
with infected fractures, extraoral immobilization is critical, at least initially—“In
the presence of infection…open reduction is definitely contraindicated…extraoral
appliance may be required only for temporary immobilization; after the infection
subsides, one may remove the appliance and wire the fragments together”
(Adams 1943).
The advanced protocol in 1943 for a zygoma fracture started with incisions made
over the frontal bone. A hole was bored to accommodate a 25- or 26-gauge wire.
Next, “The wire is threaded through the opening, looped, and both ends are passed
together along the anterior wall of the antrum into the upper sulcus over the second
molar…” (Adams 1943). The fractures were reduced, and wires secured to the den-
tition as a stable point. The authors simplified the procedure to only requiring “min-
imum amount of time and equipment: a small drill, pair of pliers, spool of small
stainless steel wire, and a dissecting set” (Adams 1943). Ultimately smaller frag-
ments could be wired together via trans-osseous wires, and then larger segments
such as malar fractures were immobilized to either the teeth in the maxilla or man-
dible via a suspension wire from the orbital rim, for instance. If the patent was
edentulous, wires were attached to dentures, or in cases of no dentures, wax was
molded around the ridges and wires were tied to each other over the palate in the
midline (Adams and Adams 1956).
Finally, it was common practice to use packings, such as thin collagen tape or
rubber dam packing to help support arch fractures, orbital floors, or anterior maxil-
lary sinus wall fractures. This is not done routinely today. In the late 1930s through
the war years, the text written by Norman Rowe and Wiley Kelly opened many
avenues for the treatment of facial fractures from the 1960s to the early 1970s. One
technique for the anterior maxillary fractures was the use of iodoform gauze coated
with Whitehead’s varnish to pack out the malar eminence. It was introduced through
an inferior turbinate incision and packing the sinus and malar eminence. There were
two types of external pin fixation—First is the Roger Anderson appliance, an erec-
tor set type external apparatus that was most useful in combat situations as being
fast and easy to place and stabilize fractures until more definitive care could be
undertaken. In the civilian world the Joe Hall Morris biphasic pin fixation tended to
replace the Roger Anderson pin fixation. It used wider screws that were more stable.
With the introduction of plates and screws made of noncorrosive metals and the top-­
down approach with rigid internal fixation, there were other methods introduced.
It is clear that zygomatic and midface fractures have seen multiple new tech-
niques and instruments being introduced for their management. However, the basic
principles largely remain the same. Each surgeon will always have their preferred
approach, instrument, and technique, which will all hopefully be optimized for the
finest patient care.
170 M. S. Forman et al.

4.1 Modern Treatment

In the modern age, there now exist a number of new areas of technological develop-
ment to help guide the surgeon in the management of midface fractures. Computer-­
assisted surgery in the form of presurgical analysis and planning and intraoperative
navigation and assessment have revolutionized maxillofacial surgery for more pre-
dictable outcomes and shorter operating times. The age of three-dimensional imag-
ing in medicine began in 1971 when Sir Godfrey Hounsfield developed the computed
tomography scan, which allowed for unprecedented analysis of anatomy. Diagnostic
imaging was advanced further in 1983 when Charles Hull developed 3D printing,
allowing the first 3D milling of human anatomic structures in Germany and the
USA in 1985 (Metzger et al. 2008). In the 1990s, intraoperative navigation system
based on computed tomography technology was developed in Germany and quickly
adopted in operative practice for numerous surgical specialties (Ewers et al. 2005).
Coinciding with these technological advancements was the development and com-
mercialization of software to analyze and manipulate 3D data which allowed for the
application of this technology to virtual surgical treatment planning. Planning soft-
ware can segmentalize the various facial subunits, provide better three-dimensional
visualization of the injury, and guide the appropriate course of management. 3D
printing offers the opportunity to manufacture accurate stereolithic models by steer-
ing a laser, guided by data from a conventional CT scan, onto selectively solidifying
ultraviolet-sensitive liquid resin, creating an integrated solid counterpart of the CT
slices (Schramm et al. 2006). From these stereolithic models, preformed custom-
ized hardware and cutting guides can be fashioned to assist the surgeon in complex
reconstructions to produce more predictable and optimal results. 3D images and
models also allow for a more interactive discussion with the patient and allow for
better understanding of the extent of the injury and proposed treatment (Fig. 3). The
same benefits can also be realized when training surgical residents in an educational
environment.
Traumatic injuries cause significant alteration in both the soft and hard tissues of
the face. These insults cause considerable distortion of the regional anatomy as well
as destruction of surrounding structures, making the reconstruction a very challeng-
ing task. Over time, intraoperative navigation technology has become more readily
accessible and user-friendly. The patient’s anatomy is registered with a preoperative
computed tomography scan with excellent accuracy. Virtual surgical planning soft-
ware can be used to simulate the contralateral position of a fractured bone to give a
planned position for reduction. This is especially useful in zygomatic fractures as
the three-dimensional nature of a fractured zygomatic complex makes them chal-
lenging to orient during surgery to allow for optimal reduction. Real-time probe
based on navigation systems can then be used to achieve and verify the desired posi-
tion and is most useful in instances of positioning large orbital plates and commi-
nuted zygoma pieces where surgical access may be restricted. Intraoperative
computed tomography scans give surgeons the unprecedented ability to check frac-
ture reduction and hardware positioning in the operative field, thereby improving
Midface Trauma 171

Fig. 3 (a) Three-dimensional reconstruction of pre- and postoperative CT maxillofacial imaging

for a zygomaticomaxillary complex fracture. The postoperative image demonstrates the use of
titanium miniplates across the fracture lines and a titanium mesh to maintain skeletal dimensions.
(b) Virtual surgical plan with use of marking and positioning guides to reposition the left zygoma
based on the uninjured, right zygoma

accuracy and reducing the need for take-back reoperations. In the setting of zygo-
matic fractures, this technology can be used to assess facial symmetry and orbital
floor hardware positioning after the soft tissue retraction has been released (Klug
et al. 2006).
With the development of miniplates and rigid fixation, increased points of fixa-
tion for zygomatic and associated mid to upper face fractures have allowed for
172 M. S. Forman et al.

improved three-dimensional stability and more accurate anatomical reduction. With

the advent of virtual surgical planning, custom plates designed to provide accurate
adaptation to the patient’s post-reduction anatomy can be milled, thereby decreas-
ing intraoperative time needed to contour the plates and providing more optimal
outcomes.

5 Nasal Bone Fractures

Like the other facial fractures reviewed in this chapter, the treatment of nasal bone
fractures was first described in the Papyrus, with techniques dating back to
1700 BCE (Breasted 1930). Among the near 50 cases, four (cases XI–XIV) are
focused on isolated nasal injuries. In the first case, case XI, the book explains the
diagnosis of a fractured nasal bone, “If thou examines a man having a break in the
column of his nose, his nose being disfigured, and a depression being it…(and) he
has discharge blood from both his nostrils. Thou shouldst say concerning him: ‘One
having a break in the column of his nose. An ailment which I will treat.’” The treat-
ment involved in at least 1700 BCE, as translated in the Papyrus, was, “Thou should
cleanse (it) for him [with] two plugs of linen. Thou shouldst place two plugs of linen
saturated with grease in the inside of his two nostrils. Thou shouldst put [him] at his
mooring stakes until the swelling is reduced. Thou shouldst apply for him stiff rolls
of linen by which his nose is held fast. Thou shouldst treat him afterward [with]
grease, honey (and) lint, every day until he recovers” (Breasted 1930). Of note, a
few main treatment principles have carried through the last thousand years: utilizing
a nasal packing, waiting for swelling to subside, and firm external, rigid support.
The principles of nasal bone fractures have not advanced significantly over the
past few thousand years. Early texts advocated for reduction by inserting either
fingers or firm instruments for manual manipulation and reshaping, followed by
nasal packing and rigid support.
Other historical works with regard to the management of nasal bone fractures
were discovered in 1844 when Francis Adams translated The Seven Books of Paulus
Aegineta into English (Skoulakis et al. 2008). Paul of Aegina (CE 625–690) was a
Greek physician and surgeon. His sixth book that was translated in 1844 focuses on
surgery and medicine. Paul of Aegina understood that the nose had an “under
part…being cartilaginous does not admit of fracture, but is liable to be crushed flat-
tened, and distorted; but the upper part being of a bony substance is sometimes
fractured” (Adams 1844). He advised against large bandaging of the nose which he
observed contributed to distortion. He described his treatment as, “When, therefore,
the nose is fractured in its under parts, having introduced the index or little finger
into the nostril, he pushes the parts outwards to their proper position. When the
fracture is of the inner parts, this is to be done with the head of a probe immediately,
during the course of the first day, or not long afterwards, because the bones of the
nose get consolidated about the tenth day. They are to be put into the proper position
with the index finger and thumb externally. In order to prevent the bones from
Midface Trauma 173

changing their position, two wedge-like tents, formed of a twisted, linen rag, are to
be applied, one to each nostril” (Adams 1844). His solution for maintaining space
for adequate respiration, he described, “sewing the quills of the feathers of a goose
into the rags…they may preserve the parts in position without obstructing the respi-
ration; but this is unnecessary, as respiration is carried on by the mouth” (Adams
1844). At the time they utilized natural anti-inflammatories such as diachylon, vin-
egar and oil, or a cataplasm of fine wheaten flour boiled with manna or gum
(Skoulakis et al. 2008; Adams 1844). For comminuted fractures, he practiced open-
ing the wound via incision and “…removed the small bones with a hair forceps,
unite the divided parts with sutures…” (Adams 1844). Fascinatingly, all of the mod-
ern principles for closed reduction were practiced in ancient Greece. Further, a clear
attention to detail for patient’s postoperative comfort is eloquently written.
In 1898, a British surgeon, William Johnson Walsham, published in his textbook,
“Nasal Obstruction: the diagnosis of the various conditions causing it, and their
treatment,” his modification of a previously introduced forceps that allows one to
grasp and manipulate the nasal septum without crushing the columella (Walsham
1898). This convenient and useful forceps, referred to in present time as the
“Walsham forceps,” is still widely used for the same purpose.
In Keen’s series of texts throughout the early 1900s, Surgery, Its Principles and
Practice, similar treatments were advocated using manual reduction and splint
placement. By this time, general anesthesia after being demonstrated in 1846 in the
“Ether Dome,” at the Massachusetts General Hospital, started to be well described
in published texts. Further the author described that in the case of old fractures,
“under general anesthetic, the nasal bones, together with the nasal process of the
superior maxillae, broken away from their attachment by the use of a mallet and the
handle of a chisel which is protected by, rubber jacket, and placed at the point where
the fracture is desired. When the two sides have been treated, the nasal bones may
be properly adjusted and held in place…” (Keen 1909).
Following reduction, a variety of methods were used to fixate the reduction.
Previously described plaster of Paris was frequently utilized. Other nasal splints
were designed with a heavy tin, lined by dental compound for molding the best fit.
With certain depressed nasal bone fractures that require traction, two oval lead
plates were contoured to a concave form and adapted to the sides of the nose.
Subsequently, a horizontal mattress suture with soft stainless steel was thrown
through the fractured fragment and septum and back to the original side (Rowe and
Kelly 1968). All of these methods aided the development of modern techniques and
treatments for the same injuries.

5.1 Modern Treatment

The bones and cartilage of the nose provide both aesthetic and structural support for
the midface and airway; therefore, proper evaluation and management is necessary
to prevent nasal deformity and nasal airway compromise. Modern approaches to
174 M. S. Forman et al.

nasal fracture repair emphasize accurate preoperative assessment of the extent of

the nasal injury and compromised structures to allow for appropriate treatment
planning. This is aided by advances in imaging technology such as the computed
tomography scan and modern instruments such has the nasal endoscope. Advanced
imaging techniques can be used to evaluate the extent of the comminution of the
fracture and the involvement of the nasal septum and cartilage (Higuera et al. 2007).
A nasal endoscope can be used to assess the involvement of the turbinates and osti-
ums of the sinuses. Based on the information obtained, the surgeon can determine if
a closed reduction or open reduction is appropriate. Closed reduction is generally
reserved for simple, noncomminuted nasal fractures where the key principle is to
apply a force opposite to the vector of injury to achieve bone reduction (Verwoerd
1992). An important part of presurgical evaluation is to understand that certain nasal
injuries cannot be sufficiently managed with a closed reduction. Comminuted frac-
tures with severe loss of nasal support, severe septal injuries, and injuries with con-
siderable soft tissue damage should be addressed with an open reduction. The
greater exposure of anatomy allows for direct visualization and precise reduction of
dislocated structures. In addition, any septal injury can be visualized via the tradi-
tional transfixion or hemitransfixion incision in the membranous septum.
Development in rhinosurgery reconstructive techniques via various cartilage grafts
has also improved the functional and esthetic outcomes in surgical repairs of nasal
fractures (Rohrich and Adams Jr. 2000).
All reduced fractures, whether open or closed, should be splinted postopera-
tively. This may include internal as well as external splinting. Intranasal Doyle
splints are recommended because they provide internal septal stabilization, aid in
airway maintenance, and prevent synechiae after substantial manipulation.
Extranasal splints such as a Denver splint made from aluminum and memory foam
are now used as the modern counterpart of the lead plates used in the early twentieth
century (Cox 3rd. 2000).

6 Conclusion

The diagnosis and treatment of midface trauma has been described for thousands of
years. Many of the earliest principles still guide us today and have survived all of
the technological advances we have seen. The evolution of the surgical treatment of
midface trauma is also consistent with the evolution of oral and maxillofacial sur-
gery as a specialty. Midface trauma is among the earliest surgeries oral and maxil-
lofacial surgeons treated. Further, midface trauma treatment evolved in concert with
the evolution of warfare, in particular ballistic warfare. In response to the need,
World War I surgeons such as Gillies and Kazanjian developed techniques and prin-
ciples of midface trauma management that are still in use today.
The surgical management of midface fractures has evolved throughout history to
allow for more accurate reduction and fixation of fractured facial structures. With
improved understanding of surgical technique and advances in anatomical imaging
Midface Trauma 175

and rigid fixation, treatment of facial fractures has become increasingly predictable,
customized, and refined. The use of computer-aided surgery continues to impact all
areas of surgery, with maxillofacial surgery significantly benefiting from recent
technological advancements. The ability to three-dimensionally visualize fractures
and its influence on the surrounding anatomy allows the surgeon to accurately plan
the reconstruction. With the development of software programs to manipulate image
information and with the aid of the stereolithographic models made possible by
advancements in 3D printing, a precise planning of the reconstruction can be trans-
ferred from the presurgical model surgery to the operating room. The optimization
of the reconstructive component allows for not only decreased operating time and
morbidity but also improved functional outcome and aesthetics.

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Mandibular Trauma

Carlos R. Hernandez, Daniel E. Perez, and Edward Ellis III

1 Introduction

The earliest account of mandibular fractures is found in the Edwin Smith Surgical
Papyrus, which was acquired by Smith at Luxor in 1862 and later translated by
James H. Breasted in 1930 (Mukerji et al. 2006; Thoma 1944). The papyrus was
written sometime in the Pyramid Age (3000–2500 BCE) (Thoma 1944). Breasted’s
translation of dealing with a mandibular fracture involves the following:
If thou examines a man having a fracture in his mandible, thou shouldst place thy hand upon
it. Shouldst thou find that fracture crepitating under thy fingers, thou shouldst say concern-
ing him: One having a fracture in his mandible, over which a wound has been inflicted, thou
will a fever gain from it. An ailment not to be treated. (Rowe 1971)

Therefore, the Egyptians at this time did not have much hope for patients with
compound fractures of the mandible. This papyrus also illustrates how treatment of
simple mandible fractures in these times consisted of the following:
Applying bandages obtained from the embalmer, and soaked in honey and white of egg,
while wounds were treated by the application of fresh meat on the first day, a method which
may well have introduced tissue enzymes and thromboplastins without, one hopes, too
many associated bacteria. (Rowe 1971)

C. R. Hernandez (*) · D. E. Perez · E. Ellis III

Department of Oral and Maxillofacial Surgery, UT Health San Antonio,
San Antonio, TX, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 177

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_12
178 C. R. Hernandez et al.

2 The Hellenic Period

In 400 BCE, Hippocrates, also known as “the Father of Medicine,” began devising
his own methods to treat mandibular fractures. He advocated the use of gold or linen
threads to tie teeth on either side of the fracture for fixation (Rowe 1971). He
described the following regarding immobilizing and reapproximating fractures of
the mandible:
In fractures of the lower jaw, when the bone is not fairly broken across, and is still partially
retained but displaced, it should be adjusted by introducing the fingers at the side of the
tongue and making suitable counter-pressure on the outside; and if the teeth at the wound
be distorted and loosened, when the bone is adjusted they should be connected together, not
only two but more of them, with a gold thread if possible, but otherwise with a linen thread,
until the bone is consolidated, and then the part is to be dressed with cerate, a few com-
presses, and a few bandages, which should not be very tight, but rather loose. (Thoma 1944)

Hippocrates not only taught ways of reducing and immobilizing a fractured man-
dible but is also credited with devising the technique of reducing a dislocated man-
dible (Thomaidis et al. 2018). This method, which is still used, is described as
follows:
The patient is put in a lying or sitting position, while an assistant must hold the head tightly
in a steady position. The physician grabs the mandible with his two arms from inside and
outside the oral cavity, from both sides, left and right, performing 3 manipulations simulta-
neously. He lifts up the mandible, pushes it backwards while closing the oral cavity, all at
once. Painkillers should be given. The mandible should be fixed in its normal position with
the aid of bandages. (Thomaidis et al. 2018)

3 The Early Medieval Period

In the period of the Roman Empire (23 BCE–CE 410), the Romans continued to
rely on the principles of immobilization and repositioning established by Hippocrates
(Rowe 1971). In 30 BCE, Aulus Cornelius Celsus recommended the following tech-
nique for fixation after setting the fractured segments of the mandible in place:
Tie together the two teeth nearest the fracture with a silk thread, or else if these are loose,
the next ones. After this a thick compress should be applied dipped in wine and oil and
sprinkled with flour and powdered olibanum. This compress is to be fixed in place by means
of a strip of soft leather with a longitudinal slit in the middle to embrace the chin, the two
ends being tied together above the head. (Thoma 1944)

Furthermore, Celsus instructed his patients to not speak and to adhere exclu-
sively to a liquid diet for several days (Mukerji et al. 2006; Thoma 1944). This is
one of the earliest references of “closed treatment,” a technique that we use today to
manage non-displaced fractures.
Mandibular Trauma 179

Later, in about CE 500, Sushruta, an Indian physician, recorded a conservative

method to treat mandibular fractures in his ancient Sanskrit text on medicine and
surgery. He recommended using complicated bandaging, manual manipulation, and
heat to treat fractures of the mandible (Mukerji et al. 2006; Qureshi et al. 2016).

4 Middle Ages–Early Eighteenth Century

During the Middle Ages, there was little advancement in the management of man-
dibular fractures. Around the year 1000 CE, Abu Al Qasim Al Zahrawi (Albucasis),
one of the greatest surgeons of his time, illustrated principles for mandibular fixa-
tion using horizontal wiring adopted from Hippocrates (Thoma 1944).
From the Middle Ages to the early eighteenth century, “barber surgeons” had
taken over the management of facial fractures when the Pope “ruled any operation
involving the shedding of blood incompatible with the priestly office in 1163”
(Mukerji et al. 2006). Therefore, these barbers became a one-stop shop by providing
services such as cutting hair, extracting teeth, treating facial fractures, applying
leeches, and performing minor surgeries (Mukerji et al. 2006). The barbers adhered
to the Hippocratic principles of management of jaw fractures by manually reducing
the fractured segments, wiring the teeth adjacent to the fracture site, and immobiliz-
ing the jaw with bandages (Mukerji et al. 2006) (see chapter Barber-­Surgeons).
The importance of establishing proper occlusion when treating mandibular frac-
tures was accentuated in a textbook written by Roger of Salerno in Italy in 1180
(El-Anwar 2017). Three centuries later, rigid MMF was introduced by Guglielmo
Saliceto in 1492, when he described how the surgeon should “tie the teeth of the
uninjured jaw to the teeth of the injured jaw” in patients with mandible fractures
(Rowe 1971). Saliceto’s groundbreaking concept of MMF, which is still used today,
would later remain dormant for many centuries, with no accounts of its application
until the late nineteenth century.

5 Eighteenth Century

Pierre Fauchard sparked the advent of scientific dentistry in 1728 when he wrote his
book Traité de Chirurgie dentaire (Rowe 1971; Thoma 1944). Although he did not
make direct contributions to management of mandible fractures, his comprehensive
literature for the practice of dentistry, which included the development of dental
prostheses, inspired others to develop prostheses or splints that would provide more
stability in treating mandible fractures (Mukerji et al. 2006; Rowe 1971).
In 1743, Robert Bunon described a mandibular fracture case in which the man-
dibular bicuspids had been avulsed from the effects of trauma and there was
180 C. R. Hernandez et al.

subluxation of adjacent teeth (Thoma 1944). He replaced the empty space with a
piece of ivory containing two holes and crossed threads from the second molar on
one side of the fracture to the second bicuspid on the other side and tied it very
tightly. By doing so he was able to create a single block and consolidate the loos-
ened teeth, thereby curing the fracture in less than a month (Thoma 1944).
Later in 1779, Chopart and Desault stated in their book Traite des Maladies
Chirurgicale that mandible fractures may occur at the chin, near the ramus, at the
condyle, on one side, or on both (Thoma 1944). They recommended bandages made
of “iron hooks previously covered with linen, cork, or lead leaf and placed over the
lower occlusal table or the alveolar border and then clamped down with screws and
nuts to a plate of sheet iron below the lower border of the mandible” (Thoma 1944).
They also described the effects of elevator and depressor muscles on mandibular
fragments in their book (Thoma 1944).

6 Nineteenth Century

During this century the importance of proper occlusion in fracture reduction and
stabilization, inspired by Roger of Salerno, was elucidated. Its importance has been
maintained since, and it is currently well known that there is an increase in postop-
erative complications if the occlusion is unstable when treating with rigid internal
fixation (Ribeiro-Junior et al. 2020).
There was also wide use of splints and bandages in the nineteenth century. In
1805, Boyer recommended the use of cork splints to treat mandible fractures
(Thoma 1944). Moreover, Barton recommended applying a bandage made of a roll
that was five yards long as a form of fixation in 1819 (Fig. 1). The Barton bandage
is still used at times today either pre- or postoperatively (Kademani et al. 2016).
Gillespie, in 1836, used a piece of sole leather between the teeth on both sides and
passed a bandage around the head and another one around the chin. Following the
advent of ether anesthesia (1846), Gordon Buck became the first to apply metallic
fixation to a mandible fracture by using intraosseous wiring in the United States in
1847 (Ellis 1993; Rowe 1971; Thoma 1944).
Hamilton introduced the gutta-percha splint in 1855, claiming improved stability
over Boyer’s cork splint (Thoma 1944). The gutta-percha was heated, molded into
wedge-shaped blocks, and placed on each side between the teeth while the jaw was
being reduced. Hamilton recommended its use together with a vertical bandage
around the head for fractures occurring within the dental arch (Mukerji et al. 2006;
Thoma 1944).
In 1858, Hayward designed a metal splint for severely dislocated fractures
(Mukerji et al. 2006). The fabrication of this splint involved taking an impression of
the lower jaw and making a cast. “The cast was sectioned at the fracture site and the
occlusion was realigned. Then, the metal splint was made to the new occlusion and
the fractured segments were forced into the splint” (Mukerji et al. 2006).
Mandibular Trauma 181

Fig. 1 Barton bandage

In the early nineteenth century, there was not much improvement in the treatment
of mandibular fractures besides the use of splints fabricated from different materials
and use of bandages. It was not until Kearney Rogers from New York applied bone
sutures to fractures of long bones, which later prompted the use of bone sutures for
mandible fractures as well (Fig. 2). The procedure involved a thread being passed
inside the mouth through the gingiva and periosteum (Thoma 1944). In 1859,
Kinloch describes a case, in the American Journal of the Medical Sciences, which
involved a compound fracture just anterior to the masseter muscle (Thoma 1944).
Treatment with wiring of the teeth and use of bandages was not effective for this
case. Therefore, he administered chloroform and via a submandibular approach
drilled a hole in each fragment. Then, he used a silver wire to bring the fractured
segments together (Rowe 1971; Thoma 1944).
In 1865, Thomas Gunning designed the “Gunning splint” specifically for Mr.
Seward, the Secretary of State to Abraham Lincoln who fell out of a carriage and
fractured the body of his mandible bilaterally. The Gunning splint was a single piece
of vulcanite with a space for eating that was attached to the hard palate and mandi-
ble using screws (Mukerji et al. 2006; Rowe 1971). The fabrication of this splint
182 C. R. Hernandez et al.

involved taking impressions of the upper and lower jaws and making casts. The
model was sectioned at the fracture site and was realigned into proper occlusion.
Then the casts of the upper and lower jaws were put in an articulator to make a
model of the splint in wax, fitting the upper and lower jaws so they were partly open
which allowed a hole for feeding in front (Rowe 1971). The Gunning splint also
provides a means for MMF for the edentulous patient currently (Kademani et al.
2016) (Fig. 3).
Later in 1871, Gurnell Hammond, a London dentist, developed a wire ligature
splint to immobilize the mandible. The creation of this splint involved taking an

Fig. 2 Bone sutures in a

Le Fort osteotomy. (UT
Health San Antonio)

Fig. 3 Fabrication of Gunning splint (present day). (UT Health San Antonio)
Mandibular Trauma 183

impression of the lower jaw and casting it in stone. The fractured segments were
realigned on the model and then an iron wire was secured to the teeth on the model.
The bar was then wired to the patient’s natural teeth. This technique is regarded as
the predecessor of arch bars and model surgery used today (Mukerji et al. 2006).
Almost a decade later, in 1880, Kingsley of New York fabricated a horseshoe-­
shaped metal tray which fit the mandible. It had two wires that were soldered to it
that extended out of the mouth so that a bandage could be adapted to the wires and
pass beneath the mandible. The metal tray was filled with heated gutta-percha and
applied over the mandibular teeth (Thoma 1944).
In 1887, intermaxillary ligation was reintroduced by Thomas L. Gilmer (Thoma
1944). He described applying this principle to a case in which his patient had a
compound fracture of the right mandibular body and a comminuted fracture of the
angle and a part of the lower half of the ramus on the left side. This is the first
account in literature of fixation of a fractured mandible by holding the lower teeth
in occlusion with the upper teeth by wire ligatures twisted together (Gilmer 1887;
Mukerji et al. 2006). He pointed out the value of wiring the lower to the upper teeth
in fixation of fractures of the mandible. Gilmer describes his procedure below:
In each fragment a hole was drilled of suitable size to just admit a No. 16 (standard gauge)
platinum wire, which was bent in the shape of a staple; the fragments having been put in
place the two arms of the staple were inserted from the lingual surface. These arms were
brought together on the buccal surface and tightly twisted, drawing the parts into close
apposition. Next, a short steel wire, No. 27, was placed around the neck of each individual
tooth of the lower jaw between the second bicuspid on the right and the second molar on the
left and the corresponding teeth of the upper jaw. The ends of each wire were brought
together and twisted, fastening it securely to the teeth. This being done, the teeth of the
lower jaw were exactly articulated with those of the upper by bringing them together and
twisting thus firmly lashing the lower to the upper jaw. To prevent lateral motion the wire of
the upper left lateral was secured to the lower right lateral; this crossing being continued
throughout, held the jaw immovable. (Gilmer 1887)

In 1890, Edward Angle, who is regarded as “the Father of American Orthodontics,”

contributed to the management of mandibular fractures by introducing special
bands that could be placed around the teeth on either side of the fracture instead of
using interosseous wiring (Rowe 1971; Thoma 1944). These bands had tiny knobs
or tubes which accommodated wires and held the fractured segment in firm contact.
For intermaxillary fixation, Angle placed bands on the upper and lower teeth on
each side of the fracture and then fixed a wire along the short arms that held the
upper and lower jaws together (Thoma 1944).

7 Early–Mid-Twentieth Century

During World War I and II, there were a myriad of soldiers who suffered extensive
maxillofacial injuries from shrapnel, bullets, and shells. The fractures involved in
these injuries were characterized by comminution and loss of bone in many cases
(Fig. 4). Surgeons were put to the test to develop reduction and fixation methods
that provided better results than ever before. Consequently, it has been noted that
184 C. R. Hernandez et al.

some of the greatest advancements in the development of treatment methods were

made during periods of war. Hippocrates regards war as “the only proper school of
the surgeon” (Mukerji et al. 2006).
The use of external fixation devices became popular in this era with many
patients presenting with compound, comminuted infected fractures of the mandible
(Fig. 5). “The Amex casque, popular with French and British military surgeons, had
an adjustable steel band, fitting around the circumference of the head, with adjust-
able cranial bands and an adjustable perpendicular rod and horizontal face bow”

Fig. 4 Radiograph of
comminuted fracture of the
mandible. (UT Health San
Antonio)

Fig. 5 External fixation devices. (UT Health San Antonio)

Mandibular Trauma 185

(Mukerji et al. 2006). Its use in facial and jaw reconstruction permitted absolute
fixation for either soft tissue or osseous fragments (Mukerji et al. 2006).
During World War I, Varaztad H. Kazanjian used wire sutures through bone frag-
ments and tied the wire to an arch bar for fixation. Kazanjian’s method of suturing
osseous fragments resulted in great success with managing severely comminuted
fractures of the mandible. He also fabricated splints and “internal vulcanized rubber
supports that prevented the face from contracting until surgeons were able to graft
bone and skin onto the damaged areas” (Mukerji et al. 2006). The wire sutures were
removed after about 3–4 weeks. Kazanjian is known for emphasizing the value of
various types of prosthetic appliances, which he inserted immediately after injuries
to support the tissues while they were still soft and flexible and to prevent unwanted
adhesions (Thoma 1944).
Kazanjian is also known for classifying fractures of the mandible by the presence
or absence of serviceable teeth in relation to the line of fracture. The classes include
the following:
• Class I: teeth are present on both sides of the fracture line.
• Class II: teeth are present on only one side of the fracture line.
• Class III: patient is edentulous (Thoma 1944).
In 1922, Robert H. Ivy modified the intermaxillary fixation technique by creating
a loop, or eyelet, in the wire ligature. Ivy loops are normally used for MMF of mini-
mally displaced fractures when the patient has a full dentition, but can also be used
when there are only a few stable teeth within the arch (Eusterman 2012; Ivy 1922;
Kademani et al. 2016) (Fig. 6). Although percutaneous nailing of fractured longs
bones was described by Parkhill in 1897, the use of Kirschner wires in the treatment
of mandibular fractures was published in 1932 (Mukerji et al. 2006; Thoma 1944;
Vero 1968). Once normal occlusion was achieved, the fractured segments were
fixed with a pin inserted transcutaneously (Mukerji et al. 2006).

Fig. 6 Ivy loops. (UT

Health San Antonio)
186 C. R. Hernandez et al.

Fig. 7 Risdon wires. (UT Health San Antonio)

In 1936, E. Fulton Risdon described a twisted type of arch wiring for MMF
(Fig. 7). He described using a wire that was twisted around the last molar tooth of
the mandible. The ends were then twisted following the contour of the mandible at
the cervical margin of the teeth to the midline. This was accomplished bilaterally.
The two twisted ends were then twisted together in the symphyseal region to form
a substitute arch bar. Ligature wires were then passed to secure the individual teeth
to the bar. This was also done on the maxilla to allow MMF. Additionally, the Joe
Hall Morris appliance, which consisted of biphasic external pin fixation, was exten-
sively used during World War II for closed reduction of comminuted fractures of the
mandible. This appliance was noninvasive and did not require concurrent MMF
(Ellis 1993; Eusterman 2012). Prior to the development of antibiotics, open reduc-
tion techniques were not widely accepted due to the likelihood of osteomyelitis or
other infections arising postoperatively, which consequently resulted in failure of
treatment (Ellis 1993).

7.1 Rigid Internal Fixation

Despite the first application of rigid internal fixation with a plate and screws being
credited to Hansmann in 1858, the most significant advances were brought on by Sir
William Lane and Albin Lambotte (Gilardino et al. 2009). From 1893 to 1914, they
experimented in the field of osteosynthesis with steel plates and screws for internal
fixation but struggled with corrosion. The earliest account of the use of true bone
plates to treat mandible fractures was by Schede, in 1888, who used a solid steel
plate held by four screws. However, it was not until the development of materials
more resistant to corrosion that internal fixation for mandibular fractures became
more popular (Gilardino et al. 2009).
In 1943, Bigelow was the first to use Vitallium, an alloy of cobalt, chrome, and
molybdenum, for mandibular fractures (Mukerji et al. 2006). In an effort to repro-
duce a material that had the inertness of Vitallium combined with the usability of
stainless steel, Leventhal in 1951 proposed the use of titanium for fractures. Whereas
Mandibular Trauma 187

many metals were tested and abandoned for use in treatment of mandibular frac-
tures and facial fractures in general, stainless steel, titanium, and Vitallium became
more widespread during the new era of internal rigid fixation for facial fractures
(Gilardino et al. 2009).
Following this, in 1949, the Belgian general surgeon Robert Danis introduced
the principle of axial compression of the fracture ends (Luhr 2000; Uhthoff et al.
2006). He recognized his goal of achieving compression between the fractured seg-
ments using a plate he called the coapteur, which “suppressed interfragmentary
motion and increased the stability of the fixation.” This principle influenced all sub-
sequent plate designs (Uhthoff et al. 2006).

8 Late Twentieth Century

8.1 Compression Osteosynthesis

Luhr developed a compression plate in 1967 which adhered to Danis’ principle of

axial compression. He is known for performing the first compression plating of the
maxillofacial area in the world. Furthermore, he set the foundation for osteosynthe-
sis to be the generally accepted treatment for facial fractures (Luhr 2000). Luhr is
also credited with developing self-threading screws, which no longer required pre-
tapping before screw insertion (Ellis 1993; Luhr 2000).
In the 1970s, Spiessl recognized that “chewing tends to distract the dental border
of a fracture line, whereas the basal border tends to be compressed.” He learned that
fixation at the basal border of the mandible does little to overcome the distracting
forces occurring more superiorly (Kellman 1995). To address this problem, he advo-
cated using a “tension band arch bar” so that forces applied during chewing could
not pull this area apart. He then applied a compression plate along the basal border.
In situations where there were no teeth to apply the tension band arch bar, or it was
difficult to apply compression forces at the superior area without damaging the
tooth roots, the use of an eccentric dynamic compression plate was advocated
(Kellman 1995). This type of plate, introduced by Schmoker and Niederdellrnann in
1973, has compression holes directed both horizontally and superiorly (Ellis 1993;
Kellman 1995). When applied properly this plate provides compression at the alve-
olar region through the superior directed screws, as well as the basal border via the
horizontal compression screws (Kellman 1995).
An alternative to the use of plates and screws for compression fixation is the lag
screw technique which was introduced in 1970 by Brons and Boering (Ellis 1993).
This technique is used when fragments of the bone overlap, and it has been shown
to work well in the symphyseal and parasymphyseal region of the mandible where
there is cortical overlap due to the curvature of the mandible (Kellman 1995). In the
case of oblique fractures, at least two screws are required to prevent rotational
movements (Ellis and Ghali 1991). In 1991, Ellis and Ghali found that the lag screw
188 C. R. Hernandez et al.

technique results in a simple yet successful way to secure the fragments in a non-
comminuted fracture of the anterior mandible (Ellis and Ghali 1991) (Fig. 8).
Finally, the mandibular reconstruction plate was designed to be strong enough to
replace a missing segment of the mandible or for cases of comminution (Kellman
1995). These plates are usually placed along the inferior border of the mandible to
avoid damaging teeth or neurovascular structures and are placed with bicortical
screws to gain additional stability (Kademani et al. 2016) (Fig. 9).

a b

c d

Fig. 8 Lag screws. (a) Technique, (b) lag screw, (c) intraoperative image of lag screw application,
(d) postoperative radiograph. (UT Health San Antonio)

Fig. 9 Mandibular reconstruction plate. (UT Health San Antonio)

Mandibular Trauma 189

8.2 Miniplate Osteosynthesis

Michelet revolutionized the technique of internal fixation through his introduction

of miniplate osteosynthesis in 1973. Before this, surgeons relied on an extraoral
approach to treating mandibular fractures due to the large size of compression plates
(Ellis 1993). Michelet’s technique consisted of using small, non-compression bone
plates placed juxta-alveolar and subapical via a transoral approach with monocorti-
cal screws.
In 1978, Champy et al., following along the technique of Michelet, advised
against the use of compression plates due the following reasons:
1. There is a natural strain of compression existing along the lower border due to
masticatory forces.
2. There is an inability to measure the amount of compression created between the
two fragments which may lead to bone necrosis.
3. The use of a rigid lower border plate will result in the “shield effect.”
4. There is difficulty in reestablishing normal occlusion with use of compression.
5. Compression osteosynthesis requires access through a transcutaneous approach.
Therefore, they advocated the use of very strong miniature and malleable screwed
plates in the subapical position without compression. This miniplate is applied with
monocortical screws in order to avoid damaging the tooth roots or the nerve
(Champy et al. 1978; Ellis 1993).
Champy also described lines of tension along the mandible that correspond with
biomechanically favorable regions for osteosynthesis (Champy et al. 1978; Koshy
et al. 2010) (Fig. 10). He advised the use of one miniplate in all these areas of the
mandible except for the symphyseal region where there are rotational or twisting
forces during function (Kellman 1995). He recommended the use of two miniplates
in this location. For mandibular angle fractures, he advocated the use of a miniplate
along the vestibular osseous flat portion located in the third molar region (Champy
et al. 1978) (Fig. 11).

Fig. 10 Champy’s ideal

line of osteosynthesis

Ideal line of
osteosynthesis
190 C. R. Hernandez et al.

Fig. 11 Champy miniplate

Fig. 12 Bone clamps. (UT Health San Antonio)

In 1973, Goode and Shinn described the use of a bone compression clamp, which
would shorten or eliminate the need for intermaxillary wiring. It was found that this
clamp held the fractured segments of the mandible in good position and promoted
bone healing at 4 weeks (Fig. 12). These clamps were attached to the buccal and
lingual cortices around the inferior border of the mandible. However, later studies
showed how this device did not provide rigid fixation of the mandible and had some
slippage (Ellis 1993; Goode and Shinn 1973).
The use of Erich arch bars provided an effective method for MMF prior to the
development of open reduction and internal fixation (ORIF) (Fig. 13). However,
there were shortcomings to their use as well. There is increased surgical time in both
placement and removal of the arch bars, the surgeon bares the risk of penetrating
injury, there is a risk of damaging the periodontium, and proper oral hygiene
becomes compromised (Qureshi et al. 2016). Therefore, in 1989, self-drilling IMF
screws were introduced by Arthur and Berardo to help overcome these shortcom-
ings (Fig. 14). They used self-tapping bone screws that were 2 millimeters in diam-
eter. The mandibular screws were placed between the root apices and the mental
Mandibular Trauma 191

Fig. 13 Erich arch bars. (UT Health San Antonio)

Fig. 14 IMF screws. (UT Health San Antonio)

foramen, whereas the maxillary screws were placed in the pyriform rim and zygo-
matic buttress areas (Qureshi et al. 2016). Some advantages of IMF screws were
minimal use of hardware, decreased operation time, and no risk of needlestick inju-
ries; however, there is still the risk of accidental root perforation (El-Anwar 2017;
Qureshi et al. 2016). Ultimately, both Erich arch bars and IMF screws offer adequate
temporary MMF intraoperatively to check occlusion (Qureshi et al. 2016).

9 Present Day

Currently, the most common treatment modality for mandible fractures is ORIF
(Ellis and Miles 2007). In spite of this, closed reduction is still commonly used in
some cases when surgery is not indicated. The location as well as the number and
severity of fractures guides the anatomical approach and hardware that can be uti-
lized. Research has also greatly expanded on the comparison of different techniques
or armamentarium for treating mandible fractures. For instance, it is now known
that the use of two miniplates results in more postoperative complications versus the
use of one stronger plate for treatment of mandibular symphysis/body fractures
(Ellis 2011).
192 C. R. Hernandez et al.

Advances in plating osteosynthesis have also decreased the need for postopera-
tive MMF (Ellis and Miles 2007). This is advantageous because it has been found
that there are detrimental effects of mandibular immobilization on the masticatory
apparatus (Ellis and Carlson 1989). Moreover, the ability to access fracture sites
intraorally, or even endoscopically in some cases, has provided a significant
improvement in aesthetic outcomes (Ellis and Miles 2007). Recently, resorbable
polymer plates have been introduced as a management technique for mandibular
fractures; however, they remain mostly used in non-load-bearing cranial and orbital
regions (Hosein et al. 2013).

10 Conclusion

Despite the significant advances in management of mandible fractures, from the

time of the ancient Egyptians to the present day, the goal of the surgeon of restoring
form and function remains unchanged.

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 Part III
Advanced Procedures
Orthognathic Surgery

Christopher S. Midtling and Timothy A. Turvey

1 Introduction

The evolution of orthognathic surgery extends almost 200 years with contributions
from generations of surgeons and clinicians across Europe and the United States.
The culmination of creative minds, innovative research, and open dissemination of
knowledge has led to the development of safe and efficient surgical treatment
options. From the countryside of West Virginia to anatomy halls in Graz, Austria, all
of the individuals who contributed to our understanding of the craniofacial skeleton,
congenital or developmental deformities, diagnoses, treatment options and plan-
ning, and technical advances have exerted a profound influence on this amazing
subspecialty.
Orthognathic surgery encompasses a broad range of procedures to correct minor
and major skeletal and dental deformities. With the ability to correct misalignment
of jaws and teeth; improve function in chewing, speaking, swallowing, and breath-
ing; reduce muscle pain and improve TMJ mechanics; and enhance facial balance
and cosmetics, it has evolved into one of the most powerful tools in the oral and
maxillofacial surgeon’s armamentarium.
A historical account of the evolution of orthognathic surgery must inevitably
focus on the contributing surgeons and their introduction or impact on various pro-
cedures. A perfect chronological description of these events is complex. The multi-
tude of operations to reposition the mandible, maxilla, and midface were often
being developed simultaneously by surgeons on both sides of the Atlantic. This
chapter journeys through more than 170 years to chronicle some of the milestones,

C. S. Midtling (*) · T. A. Turvey

Department of Oral & Maxillofacial Surgery, University of North Carolina,
Chapel Hill, NC, USA
University of North Carolina, Chapel Hill, NC, USA
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature 197

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_13
198 C. S. Midtling and T. A. Turvey

pioneers, and breakthroughs in the evolution of orthognathic surgery, focusing on

chronological history as best possible. The first section reviews its early history
through pioneering surgeons who first addressed mandibular and maxillary defor-
mities and established the specialty. The second section reviews the discovery,
establishment, acceptance of orthognathic surgery, and refinement of techniques,
with its rich history and future challenges.

2 The Pioneering Era (1850–1960s)

The origin of orthognathic surgery is traced to the mid-nineteenth century in the

rustic mining community of Wheeling, West Virginia. In 1835, medically trained
surgeon Simon P. Hullihen set out from Pittsburgh via steamboat to establish a new
practice in Kentucky (Fig. 1). He fell ill while en route and was forced to disembark
in Wheeling for medical attention. Following his recovery, he decided to settle in the
community and devote his career to surgery of the oral cavity, head, and neck. For
his exemplary work and leadership in maxillofacial surgery, he was awarded an
Honorary Doctor of Dental Surgery by the Baltimore College of Dentistry in 1842
(Turvey 2017; Goldwyn 1973). The local medical community was at first skeptical
of him, as dentists of this time were considered “barber-surgeons,” but he soon
established a reputation for surgical excellence (Aziz and Simon 2004).

Fig. 1 Photograph of
Simon P. Hullihen, “the
father of orthognathic
surgery” (Aziz and Simon
2004). (Reproduced with
permission without
alterations)
Orthognathic Surgery 199

Hullihen was a meticulous recordkeeper, often publishing case reports in both

medical and dental literature that described novel reconstructive techniques.
Unbeknownst to him, his 1849 case report entitled Case of Elongation of the
Underjaw and Distortion of the Face and Neck, caused by a Burn, Successfully
Treated, would become his most influential publication (Aziz and Simon 2004).
Hullihen described the case of the adolescent patient, Mary S., who suffered from
prognathism and open bite as a result of scar contractures after severely burning her
neck and chin at the age of five. His three-stage surgical plan included correction of
the skeletal deformity via what is now known as an anterior subapical segmental
osteotomy, followed by resection of scar tissue along the right face and neck, and
concluding with correction of the lower lip defect. He emphasized the importance
of correcting her malocclusion to provide restoration of function (Fig. 2).
The monumental milestones in this highly innovative series of operations should
not be understated: Hullihen performed a novel procedure to reposition the dentoal-
veolus of the mandible; conducted the successful operation in a pre-antibiotic and
pre-anesthetic era; and recognized that release of soft tissue scarring, which precipi-
tated the skeletal deformity, was required to improve surgical outcome. As the first
operation of its kind in medical literature, he demonstrated that malocclusion and
jaw deformity could be treated with surgery, thus igniting the development of
orthognathic surgery.
Widely acclaimed as “the father of oral and maxillofacial surgery” in the United
States, Hullihen was the first surgeon known to limit his scope to the face and neck.
Throughout his career in the Ohio River Valley, he conducted more than 1100 max-
illofacial surgeries from oral cancer resections to cleft lip and palate repairs. His
most lasting legacy in Wheeling, however, was the founding of Wheeling Hospital

Fig. 2 Hullihen’s illustration of the first anterior subapical segmental osteotomy for a 20-year-old
patient, Mary S., who suffered severe malocclusion. Hullihen repositioned the anterior dentoalveo-
lus to re-establish occlusion and restore function (Aziz and Simon 2004). (Reproduced with
permission)
200 C. S. Midtling and T. A. Turvey

and the first dental unit in an inpatient facility. The revolutionary work of Simon
P. Hullihen paved the way for future pioneers and the evolution of this
subspecialty.

3 Early Mandibular Osteotomies

The ensuing decades saw little in the way of advances in mandibular reconstruction.
It wasn’t until 1897 when publications in Europe and the United States brought a
new wave of innovative mandibular osteotomies. In Lyon, France, surgeons
Jaboulay, Bérard, and Berger investigated the correction of prognathism via bilat-
eral subcondylar osteotomies for mandibular setbacks using an extraoral approach
(Jaboulay and Berard 1898; Berger 1897). The following year James Whipple and
Edward Angle, two orthodontists in the United States, published case reports of
prognathism corrected by surgeon Vilray Blair at Washington University (Whipple
1898; Angle 1898). In Blair’s extraoral approach, later named the “St. Louis
Operation,” he opted to conduct mandibular body ostectomies in the premolar
regions, removing the blocks of the bone to create space for a mandibular setback
(Fig. 3). The two segments were then secured with copper wire ligation. Blair, a
famed general surgeon, had soon developed a devotion for reconstructive surgery of
the head and neck.
By 1907, Blair published various methods for the correction of maxillofacial
deformities in the article Operations on the Jaw-Bone and Face (Blair 1907). He
described a novel extraoral approach using bilateral osteotomies of the mandibular
rami to protrude the mandible in a patient with retrognathia. Blair repositioned the

Fig. 3 A depiction of
Vilray Blair’s “St. Louis
Operation” (1897). His
approach consisted of
bilateral mandibular body
ostectomies in the
premolar region. Following
removal of the blocks of
the bone, the anterior
mandible was set back and
secured with wire ligation
Orthognathic Surgery 201

segments to achieve proper occlusion and secured the mandible by intermaxillary

wiring and a plaster splint. While this approach resulted in visible scarring and dam-
age to the inferior alveolar nerve (IAN), Blair’s primary concerns consisted of
relapse and nonunion. The three distinct problems he recognized in orthognathic
surgery included cutting of the bone, positioning the jaw in proper orientation, and
maintaining this placement postoperatively.
Ahead of his time in many respects, Blair’s affinity for corrective jaw surgery
awakened him to the importance of the role of orthodontists in obtaining successful
outcomes. Though he never directly published with Edward Angle – the father of
orthodontics – he often turned to him for his expertise, advice, and guidance in
treatment planning. Blair’s interest in operations of the jaw bones and face led to
several editions of the text, Surgery and Diseases of the Mouth and Jaws (Blair
1912). Angle’s own text on oral surgery, Treatment of Malocclusion of the Teeth and
Fractures of the Mandible, also went into several editions and featured corrective
surgery for malocclusion (Angle 1915). Each becoming pillars in their respective
fields, Angle and Blair are recognized as the first surgeon-orthodontist duo to col-
laborate. They established a multidisciplinary approach in pre- and postoperative
treatment planning, sequencing of procedures, and considerations for growth and
development that would become the model for modern orthognathic surgery.
Detroit surgeon Max Ballin (1908) suggested preoperative extraction of teeth in
the region of proposed mandibular body osteotomies several months prior to the
reconstructive operation (Ballin 1908). This, he argued, would reduce contamina-
tion of the extraoral surgical sites from intraoral pathogens. Ballin published a
report of a patient with class III malocclusion treated with this technique. The
patient, who suffered from maxillary retrusion and mandibular prognathism, would
have likely benefited from bimaxillary intervention; however, the ability to reposi-
tion maxilla in a stable manner had yet to be established. Consequently, many
patients of this time underwent mandibular operations to correct even primary max-
illary deformities. American orthodontist Rodrigues Ottolengui recognized this
issue and warned that if the mandible is normal in size, an effort must be made to
correct the abnormal part (i.e., maxilla), “thus making the abnormal fit the normal”
(Ballin 1908). This principle was appreciated years later as surgeons continued to
advance in the field of orthognathic surgery.
Matthew Cryer, a Professor of Oral Surgery at the University of Pennsylvania, is
credited with the founding of the first hospital dental service in America (Cryer
1913). Cryer made several contributions to oral and maxillofacial surgery (OMFS)
including “Cryer’s elevators,” which is still used in exodontia today (Naini 2017). In
1913, he suggested a semicircular osteotomy near the angle of the mandible to cre-
ate a hinge effect (Fig. 4). This technique permitted vertical rotation of the mandible
and did not require removal of any bone from the mandibular body, which Cryer felt
would decrease infection rates. However, this method often resulted in posterior
open bites and did not gain acceptance with other surgeons.
Attempts at mandibular reconstruction during the early 1900s brought universal
challenges including high rates of postoperative scarring, open bites, relapse, and
nonunions. This led to continued variations in mandibular osteotomies across
202 C. S. Midtling and T. A. Turvey

Fig. 4 A photograph of
the semicircular
mandibular osteotomy
proposed by Cryer (1913)
(Naini 2017). (Reproduced
with permission)

Fig. 5 Wassmund’s inverted “L”-type osteotomy of the mandibular ramus (1927) (Naini 2017).
(Reproduced with permission)

Europe and the United States between 1920 and 1940. Berlin surgeon Martin
Wassmund (1927), who began the “German School” of maxillofacial surgery, pub-
lished an inverted “L”-type ramus osteotomy using an extraoral approach (Wassmund
1927a). Wassmund’s technique could be used for mandibular advancement or clos-
ing anterior open bites (Fig. 5). Frantisek Kostečka (1928), a Czech surgeon,
described a closed osteotomy technique where he used a Gigli saw placed through
limited stab incisions to avoid excessive scarring (Kostečka 1934). Referring to the
technique as a “blind procedure,” he placed the wire and completed the condylar
neck osteotomy before setting back the mandible (Fig. 6). While the procedure was
straightforward and avoided large facial scars, it had the same range of complica-
tions with relapse, open bite, nonunion, parotid fistulas, and nerve injuries.
Orthognathic Surgery 203

Fig. 6 Kostečka’s 1934 modification to his Gigli saw technique. Kostečka utilized a curved needle
to place a Gigli saw. The condylar neck osteotomy was completed allowing the mandible to be
pushed up into occlusion. (Reproduced with permission without alterations)

In the United States, Armenian-born Varaztad Kazanjian (1932) was able to

reduce the rate of infection and improve the overall outcome by performing the
procedures in two stages through premolar extraction sites as opposed to the single-
staged neck approaches of prior surgeons (Kazanjian 1932, 1939). In 1936, to
204 C. S. Midtling and T. A. Turvey

address the problem of nonunion, he increased the contact area between the two
segments of the mandible by using an oblique horizontal osteotomy of the ramus
(Kazanjian 1936). Like those before him, Kazanjian preferred an extraoral approach.
By the 1940s, American surgeon Reed Dingman improved the method of man-
dibular body osteotomies. Importantly, he was one of the first to advocate for pre-
serving the IAN (Dingman 1944). Dingman published more than 150 articles and
textbook chapters in oral and maxillofacial surgery and plastic surgery. Several
years later Sanford Moose and A.C. “Cuffy” Sloan, both Americans, devised other
techniques to perform intraoral osteotomies of the ascending rami to correct prog-
nathism (Moose 1945; Sloan 1951).

4 The Sagittal Split Osteotomy

Hugo Obwegeser – the father of modern orthognathic surgery – was a young sur-
geon in Graz, Austria, when he analyzed the techniques of mandibular osteotomies
performed by his mentor, Richard Trauner, as well as those of pioneers before him
(Obwegeser 2007) (Fig. 7). His 1952 review of 36 surgical cases in his hospital
revealed that more than one-half suffered major complications including parotid
fistulas, facial nerve palsy, and relapse. Obwegeser theorized that nerve palsies and
fistulas were related to extraoral approaches and relapses were the result of minimal

a b

Fig. 7 (a) Photograph of Hugo Obwegeser, widely acclaimed as the father of modern orthogna-
thic surgery. (b) Photograph of Richard Trauner, who helped train Obwegeser in Austria
(Steinhauser 1996). Together, Obwegeser and Trauner eventually performed the first mandibular
sagittal split osteotomy. (Photographs reproduced with permission)
Orthognathic Surgery 205

Fig. 8 Obwegeser’s illustration of his first sagittal splitting osteotomy of the mandibular rami
from his 1955 publication (Obwegeser 2007). (Reproduced with permission without alterations)

contact area between bony segments. From hours studying cadaveric mandibles and
using experience from trauma patients who suffered sagittal plane fractures of the
ramus, he developed and named the “sagittal splitting osteotomy,” finding a solution
to the many problems of mandibular surgery once and for all (Fig. 8).
With the assistance of Trauner, Obwegeser performed the first sagittal split oste-
otomy of the mandible on February 17, 1953 (Obwegeser 1957). He used an intra-
oral approach with local anesthesia for a 27-year-old woman with a protruding
mandible. The procedure had been inspired by the work of Schlössmann, and
descriptions of similar operations using an oblique horizontal osteotomy were
described by Georg Perthes and Karl Schuchardt, but it was Obwegeser who per-
formed and later described the complete operation in the medical literature
(Schuchardt 1942a; Perthes 1922, 1924). Schuchardt was present to assist during
Obwegeser’s second sagittal split procedure.
Over the ensuing years, Obwegeser and others published modifications of the
operation. Surgeons including Dal-Pont, Hunsuck, Epker, and Bell, among others in
the United States and Europe, soon shared their experiences (Fig. 9) (Dal-Pont
1958; Hunsuck 1968; Epker 1977; Bell and Schendel 1977). To avoid stress on the
neurovascular bundle, Hunsuck used an incomplete horizontal osteotomy along the
medial ramus just posterior to the lingula and relied on vertical cleavage lines to
complete the split. Epker advocated for a short split and developed figure-eight wire
fixation of the two fragments, while Bell encouraged minimal soft tissue stripping
to ensure wound healing, having investigated this with revascularization studies on
rhesus monkeys. Primary advantages recognized by all surgeons included the intra-
oral approach which spared patients from facial scarring and bone-on-bone contact
over a wide surface area that promoted healing without the need for grafting.
206 C. S. Midtling and T. A. Turvey

a b c d

e f g

Fig. 9 Evolution of mandibular osteotomies through the 1960s, with date of publication. (a)
Blair’s initial proposal in 1907, (b) Schlossmann-Perthes-Kazanjian from 1922 to 1951, (c)
Schuchardt 1954, (d) Obwegeser’s first sagittal split osteotomy in 1955, (e) Obwegeser 1957, (f)
Dal Pont 1958, (g) Obwegeser 1968 (Obwegeser 2007). (Reproduced with permission without
alterations)

Throughout the 1950s, several surgeons continued to explore additional opera-

tions for mandibular setbacks. Inspired by Kostečka’s condylar neck osteotomy,
American military surgeons Caldwell and Letterman published a true vertical ramus
osteotomy using an extraoral approach in 1954 (Caldwell and Letterman 1954).
This vertical subsigmoid osteotomy (VSSO) was used for mandibular setbacks in
severe prognathism cases. Other surgeons including Robinson (1956), Hinds (1958),
and Thoma (1961) published very similar techniques using an extraoral approach
(Robinson 1956; Hinds 1958; Thoma 1961).
Orthognathic Surgery 207

5 Mandibular Subapical Osteotomies

While Simon Hullihen completed the first anterior subapical osteotomy in 1849, it
wasn’t until nearly a century later that the procedure was described further. German
surgeon Otto Hofer reported his anterior subapical osteotomy to complete a man-
dibular dentoalveolar advancement in 1935 (Hofer 1936a). Unfortunately, he sev-
ered the bilateral mental nerves with his incision. The procedure was eventually
popularized by Heinz Köle in 1959 after he published several new techniques for the
operation (Köle 1959a, b, c). By positioning his incision within the anterior vesti-
bule, he preserved the mental nerves and maintained mucosal coverage of the mobi-
lized segment. Köle created his osteotomy 10 mm below the incisor apices to ensure
preservation of the dental roots and to provide greater contact area for healing
(Fig. 10). Köle demonstrated that variations of the procedure can correct open bites,
protrusion, deep bites, or short face deformities. Common concerns by other sur-
geons remained including soft tissue healing, bone healing, survival of dentition,
and maintaining adequate perfusion of the pedicle.
Segmental subapical osteotomies were documented extensively by notable sur-
geons including Wassmund, Axhausen, Immenkamp, Wunderer, Cupar, and others
(Wassmund 1927b, 1935a; Axhausen 1934a; Immenkamp 1960; Wunderer 1962a;
Cupar 1954). It was not until the 1970s that the operation was attempted to mobilize
the entire mandibular dentoalveolus. Following his training at Henry Ford Hospital

Fig. 10 Köle’s anterior mandibular subapical osteotomy, allowing for advancement of the alveolar
process. (Reproduced with permission)
208 C. S. Midtling and T. A. Turvey

in the 1960s, Robert B. MacIntosh spent several years training at Obwegeser’s clinic
in Zurich (MacIntosh 1973; MacIntosh and Carlotti 1975). Soon after, he published
his successful experiences with total alveolar subapical osteotomies to correct aper-
tognathic conditions. MacIntosh acknowledged that with these conditions, ramus
height and masticatory muscle relationships preclude conventional osteotomies. His
technique included vertical osteotomies posterior to the last molars and continued
subapically around the mandibular arch, allowing for mobilization of the entire
dentoalveolus.
Modifications continued to be explored by several surgeons including Booth,
Buckley, and Turvey. Booth used the complete mandibular subapical osteotomy in
combination with a sagittal osteotomy to correct class II malocclusions (Booth et al.
1976). Buckley and Turvey advocated for leaving the neurovascular bundle undis-
turbed and performing the subapical osteotomy between the nerve and the tooth
roots, while the posterior vertical osteotomy was conducted through the third molar
sockets (Buckley and Turvey 1987). These procedures continue to be used with
considerable stability to correct dentoalveolar retrusion; however, it poses a threat
to the inferior alveolar neurovascular bundle and blood supply to the osteoto-
mized bone.

6 Genioplasty

In 1957, Hugo Obwegeser, with Trauner, performed the first osseous genioplasty in
a living patient in Graz, Austria (Trauner and Obwegeser 1957a, b). Through their
intraoral approach they created a horizontal osteotomy and descending fracture of
the inferior border of the mandible, leaving the free segment connected to the lin-
gual musculature. This allowed for the mobilization and advancement of the
patient’s chin (Fig. 11). This procedure had been described by Hofer 15 years prior,
after he conducted a horizontal osteotomy of the mandibular symphysis on a cadaver
(Hofer 1936b). In 1950, John Marquis Converse reported his experience using free
bone grafts placed intraorally along the mental bone to project the chin forward, but
his grafts resorbed over time (Converse 1950). Obwegeser’s intraoral operation thus
proved superior in stability and outcome.
Heinz Köle, who succeeded Trauner in Graz, published a new technique in 1968
consisting of a low-level genioplasty with removal of a wedge of bone above the
level of the genioplasty (Köle 1968). Köle’s operation was versatile as it allowed for
chin advancement with shortening in height at the same time, permitting movement
in three dimensions. Technical advances have been described including Schendel’s
(2010) description of a sagittal split genioplasty to help eliminate an hourglass
esthetic deformity seen on frontal view (Precious and Delaire 1985). Other modifi-
cations to the genioplasty including publications by Precious (1985) and Triacca
(2010) have been described, but the basic principles have remained for decades
(Schendel 2010; Triacca et al. 2010).
Orthognathic Surgery 209

Fig. 11 Obwegeser’s rendering of his sliding genioplasty to advance the chin. The horseshoe-­
shaped bone was slid forward and held in position by bilateral circumferential suturing tied over a
bite-raising splint and broad contact with the mandible (Buckley and Turvey 1987). (Reproduced
with permission without alterations)

7 The Introduction of Maxillary Osteotomies

Surgery to mobilize the maxilla lagged behind the development of mandibular oper-
ations. With more complex anatomy, the maxilla made surgical exposure more chal-
lenging and prone to blood loss. Nonetheless, the need for access to nasopharyngeal
tumors and polyps inspired progress in the development of maxillary osteotomies.
A decade after Hullihen shared his work on the mandible, the iconic German sur-
geon Bernhard von Langenbeck published the first description of a surgical osteot-
omy of the maxilla. Von Langenbeck (1859) completed the resection of
nasopharyngeal tumors exposed through unilateral infracturing of the maxilla (Von
Langenback 1859).
The surgical mobilization of the entire maxilla had its beginnings with David
Cheever, a general surgeon in Boston, when he described the first maxillary down-­
fracture in 1868 (Cheever 1870; Maloney and Worthington 1981; Halvorson and
Mulliken 2008). Cheever’s approach, known as the “double operation,” was the first
known procedure that could be described as a Le Fort I osteotomy. He completed
the operation at Boston City Hospital to excise nasopharyngeal pathology and
address complete nasal obstruction. Cheever later became chairman of the
Department of Surgery at Harvard Medical School.
Reviewing the history of maxillary osteotomies is not possible without mention
of the famed French surgeon and anatomist René Le Fort (Fig. 12). Le Fort’s treatise
Étude expérimentale sur les fractures de la mâchoire supérieure (1901) became a
landmark of the medical literature (Le Fort 1901). Le Fort reproduced facial frac-
tures in the heads of cadavers with the same implements used by street toughs in the
streets of Paris: a wooden club, an iron rod, a kick, or a throw against a marble table.
210 C. S. Midtling and T. A. Turvey

Fig. 12 Photo of René Le

Fort (1869–1951). (Public
domain photo. Reproduced
without alteration https://
commons.wikimedia.org/
wiki/File:Ren%C3%A9_
Le_Fort.jpg)

Le Fort I Le Fort II Le Fort III

Fig. 13 René Le Fort’s classification of the three predominant fracture patterns of the midface

By varying the degree of blunt forces, he discovered three predictable fracture pat-
terns of the midface and classified them as Le Fort I (horizontal), Le Fort II (pyra-
midal), and Le Fort III (transverse) planes (Fig. 13) (Dyer 1999). Despite countless
Orthognathic Surgery 211

advances in medicine and maxillofacial surgery, his findings and classification sys-
tem continue to be used and became important in orthognathic surgery.
One of the most common operations of the maxilla today, the Le Fort I maxillary
osteotomy, was first performed a quarter century after Le Fort’s publication by
Martin Wassmund of Berlin. In 1927, he described the classic Le Fort I operation
using the horizontal plane to correct post-traumatic malocclusion in a single-stage
procedure (Wassmund 1927b, 1935b). Wassmund did not release the maxilla from
the pterygoid plates to mobilize the osteotomy, preferring instead to use orthopedic
traction to advance the maxilla postoperatively.
Another Berlin surgeon, Georg Axhausen, who was Wassmund’s student and
crosstown rival, was the first to describe a complete maxillary osteotomy with sepa-
ration at the pterygoid plates in 1934 (Axhausen 1934b). This full release of the
maxilla allowed for mobilization and advancement of a malunited maxillary frac-
ture to correct an open bite deformity in a trauma patient. Most surgeons considered
the operation too dangerous to attempt because of the difficulty with access and
blood loss and the risks of relapse and postoperative necrosis. Axhausen and others
found success through transfacial incisions, multiple vertical buccal incisions, or
even palatal incisions in a staged approach to maintain adequate perfusion.
Trench warfare during World War I and the conflicts of World War II led to a
dramatic increase in gunshot wounds and trauma to the head and face. Surgeons on
both sides of the conflicts cared for soldiers with horribly disfiguring facial injuries,
resulting in extensive experience and significant advancements in reconstructive
surgery. Gillies, Schuchardt, Kazanjian, Ganzer, Rowe, Pichler, and others made
substantial advancements from their wartime experiences, particularly in the devel-
opment of facial osteotomies and reconstruction (Gillies and Rowe 1954; Bamji
2006; Schuchardt 1942b, 1955; Drommer 1986). The techniques developed for
injured and disfigured soldiers were applied with success to patients with congenital
dentofacial and craniofacial anomalies and malformations, which proved beneficial
in the advancement of orthognathic surgery.
New Zealand-born British otolaryngologist Sir Harold Gillies, who helped open
the Queen’s Hospital in Sidcup, South-East London, developed many new tech-
niques during World War I (Bamji 1993). He and his colleagues conducted over
11,000 procedures on more than 5000 patients, primarily soldiers with facial trauma.
Gillies established an international reputation as a skilled surgeon; Kazanjian and
Ivy, who were US Army surgeons in France, often collaborated with him on difficult
cases. In 1942, Gillies built on his trauma experience treating a patient with Le Fort
III fractures and became the first surgeon to publish an attempt at mobilizing the
midface to treat a patient with craniofacial dysostosis (Gillies and Harrison 1950a).
He published the case in 1950, and although Rowe was not included in the publica-
tion, Rowe was part of the surgical team. Gillies cautioned use of this approach
because of the difficulties with surgery. Contributions were made by others includ-
ing Moore, Ward (1949), and Converse (1952), though each documented their
struggles with freeing the maxilla from the pterygoid plate region (Moore and Ward
1949; Converse and Shapiro 1952).
Schuchardt (1942) was among the first surgeons to report success releasing the
maxilla at the pterygoid plates (Schuchardt 1942b). He conducted a staged Le Fort
212 C. S. Midtling and T. A. Turvey

I osteotomy, followed by pterygomaxillary separation, and used external traction

with an overhead pulley and weights to advance the maxilla postoperatively.
Converse and Shapiro documented their approach in 1952, raising extensive buccal
and palatal flaps and resulting in incomplete soft tissue coverage over the maxilla at
the conclusion of the operation (Converse and Shapiro 1952). This left many fol-
lowers with doubts about the prognosis of the maxilla, with anticipated problems in
healing and bony sequestrations, though he never reported loss of dentition or bone.
Despite the difficulty of mobilizing the maxilla from the pterygoid plates, Hugo
Obwegeser thought it essential for success in maxillary surgery and made it a criti-
cal part of his operations in the 1950s (Obwegeser 1969a, 2007). By 1965, he
described full mobilization as the key to success in this procedure and emphasized
the importance of pterygomaxillary disjunction, advancement into preferred posi-
tion, and the use of autogenous bone grafts to aid healing (Obwegeser 1965). By
1969, he described a circumvestibular incision and an intraoral approach to Le Fort
I osteotomy that left no facial scars. He felt the approach improved skeletal stability
with less risk of relapse. The bony facial structures were better positioned with
improved aesthetic appearance (Fig. 14) (Obwegeser 1969b).
Le Fort I osteotomies were also described by surgeons Dingman and Harding
(Dingman and Harding 1951) and Gillies and Rowe in the 1950s (Gillies and Rowe
1954). Gillies and Rowe (1954) discussed a segmental osteotomy in a cleft patient;

Fig. 14 Illustration of a Le Fort I type osteotomy (dashed lines indicated path of bone cuts) and
forward advancement of the maxilla by Obwegeser in 1969 (Obwegeser 1969b). (Reproduced with
permission)
Orthognathic Surgery 213

however, they relied on postoperative elastic forces to guide repositioning of the

maxilla. Swedish pioneer Karl-Erik Hogeman also applied Le Fort I osteotomies in
patients with cleft lip and palate (Hogeman and Wilmar 1967). Hogeman and
Willmar became so proficient with the procedure that they published a report on
over 100 cases they operated in 1973 (Willmar 1974).

8 Isolated Anterior Maxillary Segmental Osteotomies

Osteotomies of a segment of the maxilla were traditionally more common in Europe

in the early twentieth century. Berlin surgeon Günther Cohn-Stock (1921), consid-
ered by some to be the father of maxillary osteotomy techniques, sparked enthusi-
asm for anterior segmental osteotomies after publishing on retroclination of a
proclined anterior maxillary dentoalveolus (Cohn-Stock 1921; Wolfe 1989). The
technique began with extraction of premolars bilaterally, removal of a wedge of the
bone from the anterior dentoalveolus with a palatal approach, and retroclination of
the dentoalveolus (Fig. 15). Cohn-Stock, who was Jewish, safely left Germany for
London in 1939 with the help of Prince Bernhard of Holland, who was fortunately
one of his patients.
Martin Wassmund conducted his now famous segmental setback of the anterior
maxilla in 1935 (Wassmund 1935b). His technique included two stages: first with a
palatal approach to remove palatal bone and second with a buccal approach 4 weeks
later to remove buccal bone and set back the anterior maxilla. By 1962, Siegfried
Wunderer of Vienna developed modifications to this operation, describing a single-
step procedure from the palatal approach to preserve the labial mucosa (Wunderer
1962b). Heinz Köle was responsible for several variations of segmental osteotomies
and is credited with eventually popularizing the procedure (Köle 1959a, b, c, 1970).

Fig. 15 Cohn-Stock’s
anterior maxillary
segmental osteotomy for
retroclination of the
maxilla. Relapse occurred
within 1 month (Cohn-­
Stock 1921; Wolfe 1989).
(Reproduced with
permission)
214 C. S. Midtling and T. A. Turvey

9 Isolated Posterior Maxillary Osteotomies

By the 1950s, Schuchardt, who gained experience from his training with Wassmund,
recognized the complexity of closing open bites with only anterior maxillary oste-
otomies (Schuchardt 1955). Understanding the difficulty with aesthetics and lip
support, he proposed maintaining the upper lip to incisor relationship by creating
posterior maxillary osteotomies and moving the posterior maxilla superiorly in a
two-stage technique (Fig. 16). Schuchardt began the first stage with a palatal flap to
create bone cuts and closed the site for 3 weeks. Upon return for the second stage,
buccal osteotomies and separation from the pterygoid plates were completed. He
then used a wooden wedge and mallet to impact the posterior maxilla into the
sinuses superiorly, asking the patient to forcefully bite to assist with mobilization.
Remarkably these operations were conducted on awake patients using local anes-
thesia in a dental chair.
Five years following Schuchardt’s report, a single-stage posterior maxillary oste-
otomy was introduced by Czech surgeon Josef Kufner to close an open bite (Kufner
1960, 1970). Kufner’s contribution, which included a buccal approach with transan-
tral palatal access, unfortunately went under the radar for nearly a decade as it was
published in his native Czech language. After spending several years with Obwegeser
in Zurich, he published his work in English and presented it at the International
Congress on Oral Surgery in New York City in 1968. Kufner’s transantral approach
had proven advantageous for both access and stability of maxillary osteotomies,
which was detailed by multiple other surgeons including Perko, West, Stoker, and
Epker (Perko 1972; West and Epker 1972; Stoker and Epker 1974).

Fig. 16 Schematic drawing of Schuchardt’s posterior segmental osteotomy in the 1950s.

Schuchardt described a two-stage procedure, first with bilateral palatal alveolar osteotomies, fol-
lowed by buccal osteotomies 3–6 weeks later to elevate the posterior dentoalveolar segments (Köle
1970). (Reproduced with permission without alterations)
Orthognathic Surgery 215

10  omplete Simultaneous Mobilization of the Maxilla

C
and Mandible

As advancements were made in both mandibular and maxillary osteotomies, the

idea of simultaneous mobilization of both jaws developed. Heinz Köle was respon-
sible for several innovations in orthognathic surgery and was first to describe bimax-
illary alveolar osteotomies in the 1950s; however, he did not completely mobilize
both jaws (Köle 1959a). American surgeon Alec Mohnac also shared his work with
simultaneous osteotomies of both jaws, though like Köle his operations did not
involve complete mobilization (Mohnac 1965). Eventually Hogeman and
Obwegeser, two of the earliest pioneers of bimaxillary procedures, reported their
experiences with full mobilization of the maxilla and mandible in a single operation
(Hogeman and Wilmar 1967; Obwegeser 1970). Obwegeser was first to report the
procedure in 1970 after completing both a Le Fort I osteotomy and bilateral sagittal
split osteotomy (Fig. 17).
In the following decade, many surgeons in both Europe and the United States
began publishing their experiences with simultaneous complete mobilization of the

Fig. 17 Depiction of a simultaneous maxillary and mandibular surgical plan by Obwegeser,

including superior maxillary impaction, mandibular angle osteotomy with clockwise rotation, and
a sliding genioplasty (Obwegeser 2007). (Reproduced with permission)
216 C. S. Midtling and T. A. Turvey

maxilla and mandible. This included Americans Gross and James (1975), as well as
Germans Helmut Lindorf and Emil Steinhauser (1978) (Gross and James 1978;
Lindorf and Steinhauser 1978). This revolutionary procedure was recognized for its
tremendous versatility and usefulness in correcting multiple dentofacial deformi-
ties, particularly open bites; sagittal, vertical, and transverse dysplasias; and cases
of asymmetry. By the 1980s, simultaneous mobilization became well detailed and
many Americans began adopting the procedures into their practice. Americans
Turvey, Epker, and LaBanc documented their experiences with over 100 patients in
1982 (LaBanc et al. 1982). The use of study models and introduction of cephalo-
metric tracings, face-bow transfers, interim splints, and semi-adjustable articulators
aided surgeons as their understanding of timing and sequence of surgery expanded
significantly.

11 Multipiece Segmental Maxillary Osteotomies

The early pioneers continued to recognize the essential need for widening, leveling,
advancing, or closing spaces in the maxillary arch for both aesthetics and function.
The earliest published case reports typically involved trauma or cleft palate patients.
The idea of conducting a Le Fort I osteotomy followed by surgically segmenting the
maxilla to accomplish these moves was described by many surgeons including
Axhausen, Gillies, and Obwegeser. By the late 1970s, the work conducted by Bruce
Epker, Larry Wolford, William Bell, and Timothy Turvey, among others, provided
illustration and great details of the surgical technique (Epker and Wolford 1980;
Bell et al. 1980; Turvey 1985).

12 Midface Osteotomies

High-level midface osteotomies were not attempted until the mid-twentieth century
due to their sheer complexity. Gillies conducted the first recorded attempt at a Le
Fort III osteotomy with Harrison and Rowe in 1942, which he later published in
1950 (Gillies and Harrison 1950b). The procedure was repeated by Gillies multiple
times for patients with congenital malformations or victims of trauma; however, he
noted that surgeons should heed caution prior to attempting Le Fort III osteotomies
given the difficulty of the operation. Czech surgeons Burien and Kufner documented
their experience with midface osteotomies as well in 1958 (Kufner 1971).
The Le Fort III operation gained notable attention from surgeons across the
world after Paul Tessier showcased his extraordinary results in 1967 at the
International Meeting of Plastic Surgery in Rome (Tessier et al. 1967; Tessier 1971a,
b). Tessier further introduced the transcranial approach and demonstrated the use of
Le Fort III operations in the treatment of midfacial trauma victims, correction of
craniofacial deformities, and patients with Crouzon and Apert syndromes. Working
Orthognathic Surgery 217

alongside neurosurgeon Guiot, Tessier had spent years practicing on cadavers, plan-
ning every step, and anticipating each possible complication (Jones 2008). Together
they worked to hone their skills and improve the functional and aesthetic outcomes
in patients who previously had no surgical options available to treat their conditions.
The enthusiastic response to Tessier’s presentation was remarkable and inspired the
foundation for the field of craniofacial surgery.
Encouraged by the work of Tessier and Obwegeser, many surgeons continued to
develop and publish descriptions of high-level midface osteotomies. Joseph Murray,
considered the father of craniofacial surgery in the United States, was chief of pedi-
atric plastic surgery at Boston Children’s Hospital in the 1970s when he emphasized
the need to add dental training to medical education to bridge the knowledge gap in
craniofacial surgery. Murray and Lennard Swanson, a prosthodontist and dentist-in-­
chief at Boston Children’s, often published on the preoperative analysis, treatment
planning, sequencing, and rehabilitation of children with craniofacial deformities
(Fig. 18). As craniofacial surgery became more advanced, they underscored the
importance of collaboration beyond surgeon and orthodontist, requiring the partici-
pation of neurosurgery, ophthalmology, radiology, anesthesiology, speech and lan-
guage, and psychosocial disciplines (Murray et al. 1975).

Bone excised Grafted bone graft

Fig. 18 Sketch of a treatment plan by Murray and Swanson, showing osteotomy sites (dotted lines
in left drawing) along the maxillary, zygomatic, frontal, and nasal bones. A V-resection of the
mandibular body was proposed to correct the mandibular prognathism. The shaded regions in the
right drawing indicate areas for bone graft replacement using bone blocks from the root of the
nose, lateral orbital walls, zygomatic arches, and posterior to the maxillary tuberosities, highlight-
ing the complexity of these procedures (Murray et al. 1975). (Reproduced with permission without
alterations)
218 C. S. Midtling and T. A. Turvey

Tessier also worked to break barriers between specialties and traveled across the
world, inviting plastic surgeons, maxillofacial surgeons, pediatricians, neurosur-
geons, and radiologists to his courses and symposiums. His philosophy that “no one
man could master all techniques and be an island unto himself” inspired surgeons
from all arenas to contribute in the development of craniofacial surgery (Ghali et al.
2014). Over the ensuing decades, the works of Murray, Epker, Wolford, Edgerton,
and Psilakis, among others, contributed to a variety of new high-level osteotomies
(Converse and Wood Smith 1971; Converse et al. 1970; Converse and Telsey 1971;
Epker and Wolford 1979; Psillakis et al. 1963; Jabaley and Edgerton 1969). By the
late 1990s, the simultaneous treatment of anterior open bite and midface advance-
ment was described using a combination of Le Fort I and Le Fort III osteotomies by
Sailer in Switzerland (Sailer 1997).

13 The Discovery Era (1960s–Present)

In the hundred years after Hullihen’s first publication on surgical correction of skel-
etal deformities, pioneers from both sides of the Atlantic demonstrated the success-
ful use of surgery to correct dentofacial deformities. From the mid-twentieth century
to today, surgeons built on this foundation to discover new techniques and refine
surgical interventions described by the pioneers who preceded them. As surgeons
began analyzing treatment outcomes, they established an understanding for the indi-
cations and contraindications of each operation. Surgeons developed innovative
instrumentation which was manufactured and sold to assist others in treatment plan-
ning and performance of these operations, and the field continued to expand.

14 Hugo Obwegeser and the Paradigm Shift

Throughout the history of orthognathic surgery, there is perhaps no event more

influential than Hugo Obwegeser’s June 1966 visit to the Walter Reed Army Hospital
in Washington, D.C. Following an earlier lecture in Buenos Aires, Obwegeser was
approached by General Robert Shira, who was serving as the chief of the US Army
Dental Corps. Shira later invited Obwegeser to deliver a 3-day lecture series on the
techniques of orthognathic and other maxillofacial procedures. With more than 500
awestruck surgeons in the audience, Obwegeser captivated the crowd, igniting an
evolution in the field’s scope of practice. His landmark presentations sparked a para-
digm shift in focus among oral and maxillofacial surgeons and awakened the begin-
ning of modern orthognathic surgery (Obwegeser 2017; Naini and Hugo 2017).
During his visit to Washington, D.C., Obwegeser illustrated the correction of
craniofacial deformities using the new procedures and techniques he helped pio-
neer. These included the demonstration of mandibular setbacks and advancements
using his revolutionary sagittal split osteotomy. His technique for Le Fort I
Orthognathic Surgery 219

maxillary osteotomies was presented, which further included lectures on segment-

ing the maxilla and mandible. In addition, he shared his work on patients with cleft
lip and palate and explained applications for pre-prosthetic surgery (MacIntosh 2018).
Prior to his visit, US oral and maxillofacial surgery was considered a fledgling
specialty and was often discredited by groups of disgruntled competitors. The work
of maxillofacial surgeons was at times condemned, with desperate competitors
denouncing practitioners and seeking to bar its practice throughout US hospitals. It
was the exposition presented by Obwegeser that captured the energy of oral and
maxillofacial surgeons and empowered the development of orthognathic surgery as
a specialty within the healthcare system in the United States.
American surgeons, fascinated by the accomplishments shared by Obwegeser,
quickly accumulated experience performing these operations. Notable practitioners
including Bell, White, Walker, Costich, and dozens of others adopted his techniques,
published their experiences, and incorporated more orthognathic surgery into their
practices. By 1968, Raymond White shared his work following 17 patients he
treated successfully with sagittal split osteotomies (White et al. 1969). The same
year, Bell published his experiences with anterior maxillary osteotomies, which was
soon followed by Kent and Hinds reporting their work with the same procedure
(Bell 1968; Kent and Hinds 1971). In the words of Robert McIntosh, Obwegeser
“initiated an indebtedness in [surgeons] for all generations that is so enormous as to
be beyond reckoning” (MacIntosh 2018).
One of the most significant developments following Obwegeser’s visit was rec-
ognition for the importance of interdisciplinary collaboration between surgeons and
orthodontists. Pioneers Vilray Blair and Edward Angle realized the significance of
this partnership decades prior, often seeking each other’s advice. John Converse, a
plastic surgeon, had published with orthodontists H.H. Shapiro in the 1950s and
later with Sidney Horowitz (Converse and Shapiro 1952; Converse and Telsey
1971). It was after Obwegeser’s visit, however, that this multidisciplinary approach
became commonplace. Notable duos including Bell-Creekmore, White-Proffit,
Epker-Fish, Ware-Poultan, Walker-Murphy, Wolford-Hilliard, and West-McNeil,
among others, began publishing routinely and gained recognition in both special-
ties. By sharing a wealth of information and experiences, practitioners were able to
modify new techniques, anticipate complications, develop innovative instruments,
establish new treatment sequences, and ultimately improve outcomes.

15 The Specialty Is Named

The term “orthognathic surgery” (Greek “orthos” – straight; “gnathos” – jaws) is

attributed to Harold Hargis who coined the term in the late 1960s (Turvey 2017).
Hargis, an oral and maxillofacial surgeon in the US Army, was assigned to
Obwegeser’s clinic in Zurich in the mid-1960s to learn his innovative procedures.
There he worked alongside Bruce MacIntosh, another American surgeon sent by
Fred Henny of Detroit, US Naval officer Bill Terry, and Obwegeser’s first trainee
220 C. S. Midtling and T. A. Turvey

Emile Steinhauser. Following his return from Europe, Hargis continued to refine
orthognathic techniques, invent various surgical instruments, and would go on to
become chairman of oral and maxillofacial surgery at the University of California-­
Los Angeles.

16 The Acceptance of Orthognathic Surgery

Skeptics of orthognathic surgery as an option for cranio- and dentofacial abnormali-

ties pointed to concerns about the maxilla’s vascular supply following complete
mobilization. It was William Bell’s investigations into blood supply and revascular-
ization after surgery that proved critical to this understanding (Rhinelander et al.
1968; Bell 1969, 1973; Bell and Levy 1970; Bell et al. 1975). Bell investigated flap
designs to aid maxillary osteotomies and studied bone healing using the microan-
giographic techniques described by Rhinlander. In 1970 he published his explora-
tion on wound healing after completing maxillary osteotomies in adult rhesus
monkeys. These successes paved the way for subsequent publications, including
Bone healing and revascularization after total maxillary osteotomy authored by
Bell and Fonseca in 1975. Bell’s innovative contributions confirmed what had been
clinically known: that vascular circulation to the osteotomized segment is main-
tained when a viable buccal or palatal pedicle remained intact (Fig. 19). These
groundbreaking studies provided the biological basis of orthognathic procedures
and led to its acceptance as a legitimate and safe treatment option for patients.
Another lingering concern in the 1970s was acceptance of orthognathic surgery
by the orthodontic community and the long-term stability following surgery. The
postoperative adaptations and stability of the maxilla and mandible were investi-
gated extensively by world-renowned orthodontist William Proffit et al. (2003a).
Proffit, among other orthodontists, published widely on the changes in bite forces,
tongue and lip pressures, breathing patterns, speech and velopharyngeal function,
and other neurosensory changes after orthognathic surgery. There is probably no
one else more responsible for the explosive acceptance of orthognathic surgery by
orthodontists than Proffit. In 1979, Proffit, Turvey, and biostatistician Ceib Phillips
were awarded an NIH grant to analyze the long-term stability of orthognathic sur-
gery (Turvey 2017). This grant extended for nearly four decades and produced hun-
dreds of manuscripts and abstracts describing the topic. The efforts from this grant
helped build a data bank at the University of North Carolina which includes records
of more than 8000 patients treated with orthognathic surgery. Proffit, Turvey, and
Phillips shared their extensive findings on the topic and produced a hierarchy of
stability and predictability following orthognathic surgery (Proffit et al. 1996, 2007).
Throughout the early twentieth century, several publications of major textbooks
dedicated to head and neck surgery were released. None, however, had been devoted
to orthognathic surgery. Fundamental to the acceptance of orthognathic surgery as a
surgical treatment was the release of several such textbooks. The 1964 text by
Reichenbach, Köle, and Brückl titled Surgical Orthodontics is recognized as the
Orthognathic Surgery 221

Apical
vessels

Intra-alveolar
Labial vessels
artery
Palatal
plexus
Periodontal
plexus

Gingival
plexus
Pulp
plexus

Fig. 19 Bell and Fonseca’s schematic diagram of the vascular supply to the anterior maxillary
dentoalveolus. Bell emphasized the various anastomosing vessels which permits maxillary oste-
otomies to be completed without compromising vascularity and allowing for adequate reperfusion
postoperatively (Naini 2017). (Reproduced from Naini with permission)

first influential textbook for European maxillofacial surgeons and remains a stan-
dard work today (Reichenbach et al. 1964). Edward Hinds and Jack Kent, two sur-
geons from the University of Texas-Houston, co-authored Surgical treatment of
developmental jaw deformities in 1972, the first orthognathic surgery textbook in
the English language (Proffit and White 1991). Bell, Proffit, and White released a
pivotal three-volume text in 1980, while Epker and Wolford published their distin-
guished textbook the same year (Epker and Wolford 1980; Turvey 1985). Four addi-
tional texts by Proffit and White as well as Epker, Fish, and Stella have documented
the advances since that time (Proffit and White 1991; Proffit et al. 2003b; Epker and
Fish 1986; Epker et al. 1999).
By 1986, Raymond White and orthodontist Robert Vanarsdale introduced The
International Journal of Adult Orthodontics and Orthognathic Surgery, an interdis-
ciplinary periodical dedicated to the subspecialty. The journal ran for nearly two
decades, providing groundbreaking information, illustrating case history, explain-
ing latest research results, and helping perfect clinical treatments. As of 2021, many
texts have been dedicated to the review and practice of orthognathic surgery,
222 C. S. Midtling and T. A. Turvey

including the notable Essentials of Orthognathic Surgery by Johan Reyneke of

South Africa and the two-volume comprehensive review, Orthognathic Surgery:
Principles and Practice, by Jeffrey Posnick (Reyneke 2010; Posnick 2014). These
classic works, among others, have illustrated the various procedures and allowed
other surgeons to follow the steps of orthognathic operations and avoid complica-
tions experienced by the early founders.

17 A Global Specialty

American surgeons grew hungry to experience and develop skills in orthognathic

techniques following Obwegeser’s visit. It was common for surgeons to travel to
Europe to observe Obwegeser’s work and to participate in surgeries with Paul
Stoelinga and Henk Tiedeman in the Netherlands. Notable French surgeons such as
Jacques Dautrey and Maxime Champy, who were strong advocates instrumental in
the development of orthognathic surgery in France, were gracious hosts to visiting
surgeons. The skilled cleft surgeon, Jean Delaire from Nantes, who developed
methods for facial analysis and treatment algorithms, also commonly hosted visit-
ing surgeons. The father of craniofacial surgery, Paul Tessier of Paris, was widely
known to host fascinated visitors wishing to understand his techniques and learn
orthognathic and craniofacial procedures.
In addition to those who traveled abroad to develop new skills and learn orthog-
nathic surgery, many surgeons in the United States made efforts by developing con-
tinuing education courses (Fig. 20). William Bell, Bruce Epker, Raymond Fonseca,
Raymond White, and Larry Wolford began conducting courses, lectures, and mini

Fig. 20 Dr. Hugo Obwegeser with Drs. Bill Terry and Timothy Turvey at the 2011 annual meeting
of the American College of OMFS in Las Vegas, NV. At the meeting, Dr. Terry presented a special
tribute to Dr. Obwegeser commemorating his lifelong contributions to the field of oral and maxil-
lofacial surgery. From left to right: Hugo Obwegeser, Bill Terry, Timothy Turvey. (Photo courtesy
of Timothy Turvey)
Orthognathic Surgery 223

residencies. These efforts were not exclusive to surgeons and included collaboration
with orthodontists such as John Casko, Charles Fish, David Hall, Frank Hilliard,
Harry Legin, William Proffit, and Robert Vanarsdale. The collaborative efforts made
toward continuing education in orthognathic surgery have been unparalleled by any
other area of interest in maxillofacial surgery.

18 Refinements of Orthognathic Surgery

Advancements in orthognathic surgery continued to develop throughout the late

twentieth century. The work of Larry Wolford, a prolific surgeon, lecturer, inventor,
and innovator in TMJ surgery, introduced the combination of orthognathic surgery
in conjunction with TMJ procedures. Wolford eventually introduced total alloplastic
joint replacements conducted at the same time as orthognathic surgical interven-
tions. Talented surgeon Bruce Epker, a gifted writer and speaker, investigated surgi-
cal techniques, postoperative stability, and adaptations through statistical review
and data analysis. He published over 200 peer reviews and manuscripts and contrib-
uted many chapters to various texts, including six of his own.
Robert V. Walker, a giant in the field of oral and maxillofacial surgery, founded
the OMFS clinic at Parkland Memorial Hospital (University of Texas Southwestern
Medical Center), which soon became the epicenter for orthognathic surgery in the
United States. He recruited William Bell and Bruce Epker to faculty positions at
UT-Southwestern in Dallas, Parkland Memorial Hospital, and John Peter Smith
Hospital. This move proved instrumental in providing them the pathway, environ-
ment, and resources to blossom professionally and create a powerhouse for orthog-
nathic surgery. Walker, Bell, and Epker’s efforts sowed the seeds for the specialty,
contributing to the training and development of an entire generation of leaders and
specialists in orthognathic surgery. This includes the likes of Raymond Fonseca,
Timothy Turvey, Douglas Sinn, Roger West, Stephen Schendell, Ghali Ghali,
Richard Finn, Caesar Guerrero, and Scott Boyd, among others, who have collec-
tively contributed to thousands of peer-reviewed articles, publications, and text-
books in craniomaxillofacial surgery and have left a profound impact on the
surgeons they have trained.
Pivotal to provider success with orthognathic surgery was the development of
useful and efficient instrumentation. Today, various companies produce and distrib-
ute instruments for surgeons worldwide. One of the first to do so in the United States
was Walter Lorenz, who established his surgical instrument company in New York
City in the 1960s (Turvey 2017). He initially traveled personally from practice to
practice, marketing, selling, and servicing instruments for his clientele. Lorenz was
a strong advocate for oral and maxillofacial surgeons, and his resilient support for
the field developed into a mutual relationship. The Walter Lorenz Instrument
Company soon became a leading maxillofacial instrument developer and distributor
worldwide with high-quality, ergonomic instruments conducive to complex orthog-
nathic procedures. Most equipment sold by Lorenz was manufactured in Tübingen,
224 C. S. Midtling and T. A. Turvey

Germany, and the Walter Lorenz Company was the exclusive distributor of
Obwegeser’s original instruments.
From the 1970s through 1990s, surgeons expanded the role of soft tissue proce-
dures in conjunction with orthognathic surgery. John Hovell (1956) of London rec-
ognized the utility of simultaneous soft tissue procedures decades prior, noting the
common problem of excessive submental fullness after mandibular setback proce-
dures (Hovell 1956). Turvey and Epker (1974) acknowledged the improvement of
facial balance through orthognathic surgery with adjunct soft tissue interventions,
and Epker later published a textbook on such topics in 1994 (Turvey and Epker
1974; Epker and Wolford 1977; Epker 1994). Interest in cosmetic surgery among
the OMFS community was further advanced when the American Academy of Facial
Plastic Surgery and American Academy of Cosmetic Surgery began sponsoring
educational training courses that allowed maxillofacial surgeons to learn new tech-
niques. Procedures including rhinoplasty, rhytidectomy, blepharoplasty, submental
liposuction, platysma plication, and forehead lifts were explored as interventions
that could be done in conjunction with orthognathic surgery with minimal wound
healing complications and quicker recovery. Adapting simultaneous soft tissue sur-
gery became increasingly popular as surgeons like Epker, Sinn, Waite, Niamtu,
Ghali, Griffin, and McBride began emphasizing the benefits (Waite and Matukas
1991; Niamtu 2011; Griffin and Kim 2010; Sinn and Ghali 1996).
Near the turn of the century, leaders in the field published works highlighting the
approach to diagnosis and treatment planning for deformities encountered in clini-
cal practice. This is illustrated beautifully through the works of Johan Reyneke of
South Africa (Reyneke 2010). His most recent edition of Essentials of Orthognathic
Surgery provides step-by-step protocols for facial analysis, interpretation of diag-
nostic data, and treatment planning and execution to obtain the most esthetically
pleasing results. Reyneke stresses the relationship between soft and hard tissues and
the benefits of rotating the maxillomandibular complex and explores the utility of
distraction osteogenesis and vertical ramus osteotomies.

19 Bone Plates and Screws

Over the past 50 years, craniomaxillofacial surgery has been revolutionized by rigid
or semirigid fixation of bony segments with plates and screws. With traditional
orthognathic surgery, maxillomandibular fixation (MMF) for several weeks was
often required for appropriate healing and postoperative stability. Advances in this
technology have significantly influenced management of patient care by avoiding
the need for MMF. This has allowed for orthognathic surgery to become a more
attractive and feasible treatment option for patients.
The utilization of bone plates and screws has its origin in traumatology, with
orthopedic surgeons using the system first. German surgeon Carl Hansmann shared
his experiences using a self-developed plate and screw system for fixation of
Orthognathic Surgery 225

orthopedic fractures in 1886 (Sauerbier et al. 2008). His account included two man-
dible fractures, making him the first to report on the use of bone plating in the max-
illofacial region. In 1917, German Johannes Soerensen shared his creativity after
adapting a gold ring into a small bone plate for fixation of a comminuted mandible
fracture (Soerensen and Warnekros 1917). Multiple surgeons developed primitive
bone plates and screws for use in elective maxillofacial surgery, but the focus
remained largely on trauma. Due to high complication rates, these methods fell out
of favor in the facial skeleton for several decades.
Credit must be given to Bavarian plastic surgeon Bernd Spiessl, who applied
rigid fixation to orthognathic surgery (Spiessl 1974). In 1974 he published his expe-
rience using compression screw fixation for sagittal split osteotomies with an intra-
oral approach (Fig. 21). Spiessl suggested that relapse, a known complication with
all advancements or setbacks, was arguably impossible using this method. German
surgeon Hans Luhr also worked extensively on the development of rigid osteosyn-
thesis in both trauma and orthognathic surgery (Luhr 1967, 1968, 1990). Luhr first
introduced chromium cobalt screws and plates for use in the mandible in 1967. By
the early 1970s he improved upon miniplates developed by French surgeons
Michelet, Festal, and Champy and by 1979 had introduced a compression screw
miniplate set of his own, yielding excellent results in stabilization of the delicate
midfacial bones (Fig. 22) (Michelet and Festal 1972; Luhr 1979). Similar to Spiessl,
Luhr emphasized the principles of compression osteosynthesis for improvement in
stabilization and healing.
Other surgeons including Champy, Lodde, and Steinhauser studied the biome-
chanics of the maxilla and mandible and developed stainless-steel bone plates and
screws of their own (Champy and Lodde 1976, Luhr 1979; Steinhauser 1982). By
1986, Steinhauser had developed an all-titanium miniplate system for orthognathic
surgery (Obwegeser 1957). Contrary to Spiessl and Luhr, they felt the application of
compression screws and plates proved more difficult and hazardous for adjustments
of occlusion. A long debate over compression osteosynthesis had continued, and by
the twenty-first century it was widely accepted that compression is not imperative
for bone healing in orthognathic surgery.

Fig. 21 Fixation of the

mandible after a sagittal
split osteotomy using three
bone screws, according to
Spiessl (Steinhauser 1982).
(Reproduced with
permission without
alterations)
226 C. S. Midtling and T. A. Turvey

Fig. 22 Luhr’s first set of

miniplates that he designed
for compression
osteosynthesis in
orthognathic surgical
procedures, circa 1979
(Steinhauser 1982).
(Reproduced with
permission without
alterations)

Many surgeons across the world, including Van Sickles, Jeters, Härle, Terry, and
Tucker, among others, deserve recognition for contributions to the revolutionary
breakthrough in the understanding of plates and screws, creating new instrumenta-
tion, and developing novel techniques for internal fixation (Jeters et al. 1984; Van
Sickels et al. 1985a, b; 1999). The advantages of miniplates and screws are well
established, and applying them has become rapid and relatively simple.
Improvements in postoperative stabilization and reliability are recognized. Negating
the need for MMF provides tremendous convenience for patients and their families.
Internal fixation, most importantly, provides improved safety in the acute postopera-
tive period as patients are able to open their mouth, allowing for assessment, suc-
tion, and control of the airway if required.
In the vast majority of cases, hardware will remain in place unless it becomes
symptomatic or a source of infection. However, several countries have made it cus-
tomary to perform a secondary operation to remove all metallic hardware following
wound healing. These factors inspired the development of biodegradable plate and
screw systems to negate the need for follow-up surgery. In the 1990s, Suuronen and
Linquvist shared their development of resorbable polylactide bone plates and screws
(Suuronen 1992; Suuronen et al. 1994). Further studies have focused on the efficacy
and stability of such systems and found them to have similar success rates compared
to titanium in facial osteotomies (Landes and Ballon 2006; Turvey et al. 2006;
Blakey et al. 2014; Suuronen et al. 1999). Turvey (2011) reported his experience in
nearly 750 patients, finding success in 94% of cases and bone healing at all sites
(Turvey et al. 2011). He recognized advantages including gradual transference of
physiologic forces to healing bone, reduced need for follow-up surgery, and poten-
tial to function as a medium to deliver bone-healing proteins to the osteotomy sites.
However, improving this technology further has been limited by cost, complexity of
handling and insertion, and instrumentation.
Orthognathic Surgery 227

20 Technology Applied

The medical and surgical industries have been great beneficiaries of advancements
in technology throughout the past half century. Since 1972 when Geoffrey Walker
highlighted the use of digitized cephalometric radiographs in analysis of craniofa-
cial growth and abnormalities, their use in preoperative analysis, treatment plan-
ning, and investigation of outcomes has seen tremendous progression (Walker
1972). Like all of radiology, plain film radiographs evolved into digital format, and
ultimately three-dimensional analyses were capable through CT and MRI. Diagnostic
and treatment planning capabilities have more recently benefited through the use of
cone beam CT (CBCT) imaging. In recent years, tools such as 3D radiographs,
MRI, and innovative 3D photography have developed into valuable instruments that
will likely aid the future of orthognathic surgical planning.
Eisenfeld, Barker, and Mishelevich were some of the first to publish on the use
of computers for facial analysis and studying the correction of dentofacial deformi-
ties in the 1970s (Eisenfeld et al. 1974; Eisenfeld and Mishelevich 1980). Since that
time, software has been developed and commercialized by multiple companies to
aid in treatment planning, case studies, and data analysis. Within the United States,
companies such as Dolphin Imaging, Medical Modeling, Quintiles, and SAS
Institute have established themselves as leaders in this arena. Similar companies
have also been established in Europe.
In 2000, Jaime Gateno and James Xia from Houston published on computer-­
assisted 3D virtual surgical planning (VSP) for orthognathic surgery (Xia et al.
2000; Gatano et al. 2007). Using stereo eyewear, the surgeon held a virtual “scalpel”
(computer mouse) to operate on a 3D visualized patient. This simulation was
designed to help with presurgical osteotomy planning and prediction of bony seg-
ment movements. Belgian surgeon Gwen Swennen also pioneered 3D imaging to
assist virtual planning (Swennen et al. 2007). This technology was soon expanded
upon by entrepreneur Andy Christensen, who founded Medical Modeling
Corporation in Golden, CO. Christensen’s company worked diligently with sur-
geons including Bryan Bell to develop personalized anatomic modeling, virtual
treatment planning, and custom surgical guides, making the technology widely
available to surgeons. His company has allowed for the use of 3D reconstructions to
create accurate and detailed stereolithic skull models, which aids in treatment plan-
ning from all dimensions (Fig. 23). This innovation permitted surgical planning
without patient impressions, plaster study models, or hand-fabricated splints.
Orthognathic surgery with VSP took several years to make a significant break-
through. Early obstacles with inadequate hardware for 3D image acquisition and
meager software to diagnose, plan, and evaluate outcomes led to inefficiency in the
clinical setting. This has been addressed through the introduction of more afford-
able CBCT scanners which permitted the technology to reach a wider base of sur-
geons. Many surgeons including Farrell (2014) have discussed methods to improve
accuracy in virtual planning and execution of operations (Farrell et al. 2014). The
recent development of intraoral optical scanners has allowed for detailed mapping
of occlusal topography, permitting accurate final occlusion records and detailed sur-
gical splint fabrication which can improve operative outcomes.
228 C. S. Midtling and T. A. Turvey

Inaccuracies with conventional model surgery are often not realized during pre-
operative lab work and are typically discovered intra- or postoperatively. VSP has
allowed for early identification of such errors and opportunities to intercept discrep-
ancies. Virtual manipulation of the maxilla and mandible can address midline or
asymmetry deformities, anteroposterior or vertical movements, clockwise or coun-
terclockwise occlusal rotations, yaw and cant corrections, and importantly any
interferences requiring recontouring or anticipated needs for grafting.
Intraoperative efficiency is also improved with virtually planned custom-cutting
guides, fabricated for accurate osteotomy location and orientation (Fig. 24).
Prefabricated custom plates allow for patient-specific placement of screw holes,
numbers, and positions while avoiding anatomic structures such as dental roots,
nerves, and osteotomy margins. In lieu of traditional occlusal splints that reference
the opposing arch, Polley introduced orthognathic positioning systems (OPS) to
transfer virtual plans to the patient independent of occlusion (Polley and Figueroa
2013). The OPS allows for repositioning of the mobilized segment through refer-
ence from the stable maxilla or zygoma. Studies comparing accuracy and clinical
outcomes of VSP to conventional orthognathic planning have been favorable and
have led to a paradigm shift for many surgeons.
As orthognathic surgery progresses into the twenty-first century, surgeons con-
tinue to develop novel techniques to limit complications, facilitate safe procedures,
and improve outcomes. This most recently includes intraoperative navigation, more
commonly utilized in trauma and reconstruction, in hopes of improving accuracy of
orthognathic surgery. Maria Troulis, among others, has published on the use of
endoscopically assisted surgery for orthognathic procedures, which has benefits of
reduced procedure time, minimal blood loss, decreased recovery times, and
improvement in scarring (Troulis 2005).

Fig. 23 3D printed
stereolithic model of a
patient’s midface in the
final position after a Le
Fort I advancement. The
model can be used
intraoperatively to assist
the surgeon with orienting
the maxilla and for
pre-bending plates (Lin
et al. 2018). (Reproduced
with permission without
alterations)
Orthognathic Surgery 229

21 Distraction Osteogenesis

Russian surgeon Gavriil Ilizarov developed a single-staged operation to lengthen

long bones, repair skeletal limb deformities, and correct defects without the use of
bone grafting through distraction osteogenesis (DO) in the 1940s and 1950s (Ilizarov
1989a, b, 1992). Applying his principles to craniomaxillofacial deformities was rec-
ognized as feasible decades later when Snyder (1973) utilized Ilizarov’s methods
and introduced DO for mandibular lengthening after creating an osteotomy (Snyder
et al. 1973). Palatal expansion, which involves a naturally occurring symphysis, had
been carried out for growing patients for many decades. By the 1990s many sur-
geons including McCarthy, Bell, and Guerrero endorsed DO as a viable treatment
alternative to orthognathic surgery, highlighting the lack of need for bone grafting
and minimal invasiveness (McCarthy 1999; Bell and Guerrero 2007). The biologic
and physiologic principles of this technique are highlighted by McCarthy in his
1999 textbook, Distraction of the Craniofacial Skeleton. Guerrero, who has become
a master of this technique, demonstrated the complexity in treatment planning, post-
operative monitoring, and sophisticated analysis of esthetics and occlusion in his
textbook co-authored with William Bell. Skilled surgeons from around the world
including Walker, Chin, Polly, Rachmiel, Smith, Wangerin, Hoffmeister,
MacCormick, and Cohen, among others, have contributed to the investigation of
DO and are a testament to its success and popularity (Walker 2002; Chin and Toth

a b

Pre-drilling
cylinder with Fixation
angulation hole
control

Fig. 24 (a) CT reconstruction with patient-specific cutting guide design. (b) Two fixation holes
are located on each side of the cutting guide to secure it to the maxilla. (c) Le Fort I osteotomy
markings are indicated in red. Bony wedge will be removed on the right maxilla to correct the
occlusal cant (Greenberg et al. 2021). (Reproduced with permission without alterations)
230 C. S. Midtling and T. A. Turvey

1997; Polly and Figeroa 1997; Smith 2001; Rachmiel et al. 1995; Wangerin 2005;
MacCormick et al. 1995; Hoffmeister et al. 1998).
Distraction osteogenesis continues to be investigated for its application to orthog-
nathic surgery. Early on, its surgical devices were bulky, awkward, uncomfortable,
and placed transfacially resulting in postoperative scarring. In the twenty-first cen-
tury, most distraction devices can now be placed intraorally, hidden in hair-bearing
regions of the scalp, and have a slimmer, more sleek appearance. In 1995, Molina
projected that advancements in DO signaled a farewell to major facial osteotomies.
While this has not been appreciated, it’s application for cleft and syndromic patients
and the benefits it provides for some must be realized (Molina and Ortez-­
Monasterio 1995).

22 Orthognathic Surgery, Health, and Well-Being

The versatility of orthognathic surgery has allowed for its application to treat mul-
tiple disease processes. Waite and Wooten (1989) reported their successes in treat-
ing patients with obstructive sleep apnea (OSA) through maxillomandibular
advancements (Waite et al. 1989). Powell and Riley (2000), otolaryngologists by
training, have continued to advocate for orthognathic surgery as a treatment option
to improve symptoms and quality of life in patients with OSA (Riley et al. 2000). In
the past decade, the work of Bundell (2012) and Boyd (2013) demonstrated that
bimaxillary advancements have a superior cure rate over other treatment options
(Bundell 2012; Boyd et al. 2013). The population of patients with OSA can find
considerable improvement in symptoms and quality of life with orthognathic
surgery.
Other disease processes are occasionally associated with dentofacial deformities
such as sickle cell anemia, myopathies, fibro-osseous diseases, neurofibromatosis,
and post-radiation growth disturbances, and these patients can benefit substantially
from orthognathic surgery. These patients should not be denied treatment on the
basis of their diagnosis. Many times, safe treatment algorithms can be developed in
concert with their primary care or specialty care provider.
Orthognathic surgery has also provided a positive psychosocial impact for
patients. There is no doubt that social conditions and societal attitudes create a pro-
found impact on patients with noticeable dentofacial deformities, who often suffer
from discrimination. Sir Archibald McIndoe, plastic surgeon and cousin of Sir
Harold Gillies, demonstrated the impact of psychosocial issues in the treatment of
patients with cranio- and dentofacial deformities in the 1940s (Pinney and Metcalfe
2014). Professor Frances Cooke Macgregor, a renowned social scientist, began
researching and documenting patients with facial disfigurement during WWII in
Columbia, Missouri (Naini 2011). She became the first scholar to describe the psy-
chosocial impact of visible facial differences. Following WWII she met John
Marquis Converse, and at her suggestion he conducted an exploratory research
study of his patients with physical facial deformities (Thompson 1981). Macgregor’s
Orthognathic Surgery 231

work eventually led to the recognition of facial disfigurement as a disability by the

World Health Organization.
Since the 1980s, psychological and psychosocial changes in orthognathic
patients have been investigated further by many physicians including Kiyak,
Jacobson, Broder, Bennett, and Phillips (Kiyak et al. 1981, 1984, 1985; Jacobson
1984; Phillips and Bennett 2000; Phillips et al. 1997, 1998). Most studies have
agreed that if the surgical outcome is perceived as positive, patients do experience a
positive impact in self-concept, self-image, and confidence after surgery. Regardless
of motive for pursuing orthognathic surgery, it seems to have a positive psychoso-
cial impact on patients’ quality of life.

23 Considerations for the Future of Orthognathic Surgery

Technology will drive the future of this exciting surgical subspecialty. Just as com-
puters, bone plates and screws, and virtual planning and printing have brought us
into the twenty-first century, the application of robotics, navigation, sensors, and
many other developing technologies will mold our future. Surgeons must be open
and receptive to these changes as we progress forward.

24 Conclusion

Orthognathic surgery has evolved into a vital component of not only oral, maxillo-
facial, and facial plastic surgery but also of the entire health care community world-
wide. Generations of brilliant surgeons, anatomists, orthodontists, and researchers
have led to the discovery of safe and effective treatment options. The accumulated
knowledge and shared experiences of pioneers have helped us realize the functional,
aesthetic, and psychosocial benefits of orthognathic surgery and will remain the
foundation for future progress. The duration of time and expenses invested in treat-
ment planning, preoperative care, and recovery is undoubtedly substantial. As the
field continues to advance with new technology, surgeons must continue to improve
accuracy, decrease treatment time, and limit cost to maintain orthognathic surgery
as a viable and successful treatment option.

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Radiation Oncology

Brett H. Diamond, Utkarsh C. Shukla, Mark H. Sueyoshi,

and Kathryn E. Huber

1 Early History and Clinical Applications

The clinical application of radiation became possible with the characterization of

X-rays by Wilhelm Roentgen in 1895 (Lederman 1981). Scientists across the globe
began experimenting with this new technology and laid the foundation for the clini-
cal use of X-rays both as a diagnostic and therapeutic tool. By January of 1896,
Emil Grubbe reported the first treatment of an advanced breast cancer using X-rays,
raising interest in the utility of X-rays as a treatment for cancer (Grubbe 1933).
Likewise, early clinical experiments such as those in 1896 by brothers Gilman and
Edwin Frost at Dartmouth College resulted in physicians being able to visualize the
fractured wrist of a local schoolboy, Eddie McCarthy (Spiegel 1995). These early
applications of X-rays for both diagnostic and therapeutic purposes inspired
researchers around the globe to describe their findings characterizing this new and
exciting discovery.
Similarly, the discovery of natural radioactivity by Henri Becquerel coupled with
Marie and Pierre Curie’s discovery of radium in 1898 established high energy pho-
tons or γ-rays (“gamma-rays”) as another early tool for the clinical application of
radiation (Blaufox 1996; Mould 1998). The major distinction between γ-rays and
X-rays is their source: γ-rays are emitted by the atomic nucleus (or extra-nuclearly
in electron-positron annihilation), while X-rays come from other sources, often
from electrons transitioning between orbits of an atom or when electrons interact
with the electric field of the nucleus. Of note, the distinction is not necessarily
related to their energy and they are physically non-distinct. Soon, scientists were
experimenting with radium as a source of γ-rays in both malignant and nonmalig-
nant conditions. In 1901, Henri-Alexandre Danlos and Eugene Bloch used radium

B. H. Diamond · U. C. Shukla · M. H. Sueyoshi · K. E. Huber (*)

Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 241

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_14
242 B. H. Diamond et al.

sent from the Curies to treat skin manifestations of lupus (Mould 2007). As early as
1903, physicians in St. Petersburg, Russia, described using radium to treat and cure
basal cell carcinoma of the face (Kemıkler 2019).
During the early 1900s, scientists around the world continued experimenting
with radium as a clinical tool. Shortly thereafter, the field of brachytherapy was
born, as clinicians implanted radium directly into or near tumors, as opposed to
external beam radiation where the therapeutic dose of radiation is delivered from
outside of the body using a source that produces γ-rays or X-rays. Three general
approaches to brachytherapy were developed: (a) an intracavitary approach that
makes use of natural body cavities, (b) an interstitial approach where radioactive
seeds are directly implanted into tissue or placed on the skin surface, and (c) an
intraluminal approach where seeds are placed in a linear distribution within a lumi-
nal device that has been inserted into the body. The radioactive source placement of
intracavitary and intraluminal brachytherapy is always temporary, while interstitial
brachytherapy may be permanent or temporary. In 1903, Margaret Cleaves described
the first case of cervical cancer cured by intrauterine radium (Aronowitz et al. 2007).
Just a year later in 1904, Robert Abbe described early head and neck brachytherapy
when he applied radium, first externally, and later internally, to treat a 17-year-old
boy with a tumor of the lower jaw, likely representing the first interstitial use of
brachytherapy (Aronowitz 2012). In the subsequent decades, both X-rays and
radium-derived γ-rays were successfully applied in the treatment of a variety of
malignant and benign conditions, solidifying the utility of radiation therapy as a
practical clinical tool.

2 The Foundations of Radiobiology

Humans’ understanding of radiation has grown immensely since its first clinical
applications. Early discoveries of the clinical utility of radiation gave rise to an
entirely new field of biology termed “radiobiology.” Radiobiologists built upon
early observations to establish principles which guide our understanding of the
effect of radiation on both healthy and diseased tissues. In 1906, Jean Alban Bergonié
and Louis Tribondeau theorized early principles of radiobiology by postulating that
radiosensitivity was governed by the biologic properties of the tissue including cell
division rate, dividing future, and an unspecialized phenotype (Table 1) (Bergonie
and Tribondeau 1905). In other words, radiosensitivity of cells increased with
increased mitotic activity and radiosensitivity decreased with greater cell differen-
tiation. Similarly, scientists observing the biologic effect of radiation hypothesized
that oxygenation may play an important role in radiosensitivity. This theory was
studied by many including J.C. Mottram who in 1936 noted an increased sensitivity
of tumor cells at the edge of masses, hypothesizing that an increased oxygen supply
was correlated with increased radiosensitivity (Mottram 1936). Similarly, experi-
ments by Louis Harold Gray throughout the 1950s provided further evidence of the
presence of oxygen increasing tumor sensitivity to radiation (Gray et al. 1953).
Radiation Oncology 243

Table 1 Overview of critical events in the early history of radiation and radiobiology
1895 Wilhelm Roentgen characterizes X-rays
1896 Emil Grubbe reports first treatment of breast cancer with X-rays
1896 Gilman and Edwin Frost utilize X-rays for diagnosis of fracture
1898 Marie and Pierre Curie discover radium and Henri Becquerel describes natural
radioactivity
1901 Henri-Alexandre Danlos and Eugene Bloch utilize radium to treat skin manifestations
of lupus
1903 Russian physicians utilize radium to cure basal cell carcinoma of the face
1903 Margaret Cleaves describe the first case of cervical cancer cure with intrauterine
radium
1904 Robert Abbe describes the use of radium for early head and neck cancer used
externally and then later internally
1906 Jean Alban Bergonie and Louis Tribondeau theorize early principles of radiobiology
1913 William Coolidge develops orthovoltage X-ray tube
1920s Claudius Regaud demonstrates that radiation dose fractionation can kill rapidly
dividing cells without death of non-rapidly dividing cells via ram sterility experiment
1925 G. Failla introduces an objective method for administration of X-rays
1934 Henri Coutard describes the use of radiation dose fractionation in head and neck
cancer
1936 J.C. Mottram describes increased radiosensitivity of well-oxygenated tumor cells
1950s Louis Harold Gray provides further evidence of the role of oxygen in radiosensitivity
of tumors
1952 First megavoltage linear accelerator installed in Hammersmith Hospital in London, UK
1954 First US-based linear accelerator installed at Stanford Hospital in San Francisco,
California
1956 Theodore Puck and Philip Marcus characterize radiation sensitivity by way of HeLa
cells
1959 H.B. Hewitt and C.W. Wilson describe the radiation survival curve
1965 M.M. Elkind develops nascent rationale for fractionation which allows sublethal
damage repair for normal tissue
1985 Ian Radford confirms that double-strand DNA breaks as the primary mechanism of
cellular death by radiation
Late Further elucidation of radiation-induced free radicals as predominant mechanism of
1900s DNA damage

Paramount to the understanding of modern radiobiology is the principle of frac-

tionation, or dividing dose into multiple separate, smaller doses. In the early days of
radiation, treatments were mostly given as large single doses by placing low-energy
cathode ray tubes or radium-filled glass tubes in close proximity to tumors. These
treatments were plagued by normal tissue toxicities and disappointing cure rates.
Scientists such as Claudius Regaud began to experiment with delivery of smaller
doses of radiation in his experiments on ram spermatogenesis in order to develop a
technique to sterilize the animals with radiation. His experiments throughout the
1920s showed that dividing radiation doses into multiple smaller fractions targeting
rapidly dividing cells could result in sterility of the ram without causing severe skin
necrosis (Regaud 1977). Although the principle of dose fractionation was initially
244 B. H. Diamond et al.

controversial, further clinical evidence as to its efficacy was demonstrated by Henri

Coutard who described the use of fractionated radiotherapy in the treatment of head
and neck cancers in 1934 (Coutard 1936). These basic observations enabled further
study into developing optimal treatment regimens for a variety of cancers in subse-
quent decades. To this day, fractionation remains an important tool to optimize the
therapeutic index of radiation.
With the development and refinement of cell culture techniques, it became pos-
sible for researchers to further analyze the effect of radiation on cells. Theodore
Puck and Philip Marcus were among the early pioneers of this field with their exper-
iments characterizing the radiation sensitivity of HeLa cells, the first immortal
human cell line obtained from Henrietta Lacks’s cervical cancer, and the develop-
ment of early cell survival assays in their study published in 1956 (Puck and Marcus
1955). These assays allowed scientists to reproducibly study the effects of radiation
on cell biology. In the subsequent years, advances including the first description of
a radiation survival curve by H.B Hewitt and C.W. Wilson in 1959 allowed for fur-
ther study into the biological effects of radiation (Hewitt and Wilson 1960). Cell
culture allowed scientists to systematically study the effects of radiation to provide
a biologic basis for the observations of their predecessors. For instance, in
1965 M.M. Elkind was able to provide an early explanation for the benefits of frac-
tionation by describing how repair of sublethal damage in healthy tissue may
account for the observed decreased toxicity profile of radiation when it is split into
smaller doses rather than given as a larger single dose (Elkind et al. 1967).
As modern molecular biology techniques arose, contemporary studies confirmed
the presence of DNA damage as a direct result of intracellular ionization events and
subsequent free radical production to be the primary mediator of radiation therapy’s
lethality on tumor cells. In 1985, Ian Radford confirmed the role of double-strand
DNA breaks as the primary mechanism for radiation-induced cellular death
(Radford 1985). By the end of the twentieth century, radiobiologists were beginning
to gain a deeper understanding of the highly complex signaling cascades that
occurred as a result of this free radical-induced damage. These advancements led to
further discoveries, including radiation sensitizers, targeted therapies, and strategic
techniques in the delivery of radiation therapy which maximize its therapeutic
benefit.

3 The Modernization of Radiation Delivery

In the years since the first therapeutic use of X-rays by Emil Grubbe to treat a
patient with breast cancer in 1896, the field of radiation oncology has transformed
dramatically. Early radiation therapy, referred to as external beam therapy or tele-
therapy, was limited by devices that could produce low-energy radiation energies of
approximately 100 kiloelectron volts (keV). These energies were useful in the treat-
ment of superficial tumors, but higher-energy beams were needed to reach deeper
Radiation Oncology 245

tumors inside the body. Although beyond the scope of this chapter, it is important to
note that the maximum dose for a lower-energy X-ray beam deposits near the sur-
face, while the maximum dose for higher-energy X-ray beam deposits deeper in
tissue. Therefore, there is generally less superficial dose, and thus lower skin toxic-
ity, from a higher-energy X-ray beam (Khan and Gibbons 2014). In 1913, an
American physicist, William Coolidge, developed an X-ray tube which could pro-
duce X-rays on the order of 200 keV. For much of the 1920s, energies of 200 keV to
500 keV were utilized, later termed “orthovoltage.” By 1952, the first “megavolt-
age” medical linear accelerator was installed at the Hammersmith Hospital in
London, UK, which could generate energies up to 8 megavolts (MV) (Laurence and
Livingston 1932; Bewley 1984). Shortly thereafter, in 1954, the first such linear
accelerator in the United States was installed at Stanford Hospital in San Francisco,
California (Weissbluth et al. 1959).
In order to transform radiation from an experimental therapeutic tool to a main-
stay of head and neck cancer treatment, a deeper understanding of radiation physics
proved to be essential. In the modern era, radiation physics allows for the careful
application of reproducible doses of radiation. This arose from studies defining
ways to model radiation dose such as early reports of primitive isodose diagrams in
1925 by G. Failla (Delaney 2005). Isodose diagrams help to visual the dose distribu-
tion within both the target of interest and nearby organs. More modern isodose
diagrams take into account electron density based on CT imaging data to calculate
dose distribution which will be discussed further in the next section.
This discussion has, thus far, covered foundational radiation therapies delivered
via nuclear decay (brachytherapy), X-rays (external beam radiation therapy), and
charged particles (electrons). There are numerous other modalities of radiotherapy
that should be briefly mentioned for familiarization. For example, radiation therapy
can be delivered by way of accelerated, and thereby energized, larger charged par-
ticle radiation (protons, carbon, etc.) and uncharged particles (neutrons).
Additionally, within each modality there is further breakdown of technique.
Consider the case of external beam radiation therapy that can vary by radiation dose
per fraction, rate of radiation administration, as well as conformality of the radiation
to the target of interest. The more pertinent aspects of radiation type and delivery in
head and neck cancers will be discussed further in the following section.

4  ontemporary History of Head and Neck

C
Radiation Oncology

In the modern era, radiotherapy remains a key modality in the treatment of cancer
with approximately 50% of all cancer patients receiving radiation therapy during
their treatment (Delaney 2005). Among head and neck cancer patients, it is esti-
mated that radiotherapy is offered to nearly 75% of patients during the course of
246 B. H. Diamond et al.

their management (Ratko et al. 2014). Patients may undergo radiation therapy alone
in early-stage H&N cancers or in combination with chemotherapy in advanced can-
cers. In the field of head and neck oncology, radiotherapy has rapidly evolved to a
highly technologically advanced, multidisciplinary field. Owing to advances in
radiation treatment planning, image guidance, and treatment delivery technologies,
radiation oncologists can deliver precise and reproducible doses of radiation while
sparing normal tissues. This precision enables improved patient outcomes with bet-
ter tumor control and lower toxicities for patients and is especially vital to the use
of radiation in the head and neck region due to the intimate proximity of tumors and
sensitive organs. A notable example of toxicity is xerostomia as a consequence of
radiation to uninvolved salivary glands. The use of beam modulation often allows
for lower doses and, in some cases, avoidance of these glands. Nonetheless, despite
improved conformality of modern radiation delivery to the tumor and regions at
risk, it remains vital that oral surgeons and/or dentists play a key role in the manage-
ment of late effects of dry mouth on the health of the oral cavity even in the absence
of surgical management of head and neck malignancies (Harrison et al. 2003).
Initially, target delineation for radiation therapy delivery was based on physical
exam, plain radiographs, surgical findings, and any surgical clips placed during sur-
gery, as well as an understanding of patterns of disease spread. Early forms of exter-
nal beam radiation for head and neck cancers were of limited configurations.
Typically, radiation beams were laterally opposed fields with or without a photon
beam to cover the low anterior neck, or a “wedge pair” of 90 degree offset fields
based on 2D fluoroscopic imaging. Given the large areas of exposure with these
techniques, it was common for patients to experience severe mucositis, dermatitis,
dysphagia, and odynophagia acutely, with xerostomia and fibrosis as late toxicities
(Trotti et al. 2003).
In the late 1980s, there was a movement to reduce normal tissue irradiation with
three-dimensional conformal radiation therapy (3DCRT) as imaging quality
improved with the advent and increased availability of computed tomography (CT)
scans, thus increasing confidence in target volume delineation and radiation plan-
ning. The integration of imaging for target localization at the time of treatment,
referred to as image-guided radiation therapy (IGRT), improved the accuracy of
treatment delivery. One such technique is through cone-beam computed tomogra-
phy (CBCT), which reconstructs a 3D image from a series of 2D projection images
of the patient while on the treatment table (Jaffray 2005).
Intensity-modulated radiation therapy (IMRT) was developed throughout the
1980s–1990s and revolutionized the way radiation oncologists could deliver confor-
mal radiation. IMRT improved on the concept of conformality of radiation dose
through the use of non-uniform radiation beam intensities that can be shaped by
selectively and geometrically blocking components of the output beam as radiation
is delivered from various angles. Such an approach improved the therapeutic ratio
by increasing dose to the target tissue while simultaneously reducing dose to adja-
cent organs at risk (Hong et al. 2005). In 1994, the first commercially available
Radiation Oncology 247

IMRT capable treatment machine, the NOMOS Peacock, was released which
allowed for broader adaptation of IMRT throughout the radiation oncology com-
munity (Hong et al. 2005). The advances of 3D imaging, IGRT, and IMRT have
allowed for the reduction of radiation planning target volume that is added to
account for uncertainty in daily treatment alignment, thereby decreasing the amount
of collateral radiation to adjacent normal tissues, which translates into significantly
reduced toxicity.
Throughout the twentieth century, advances in particle physics gave rise to new
radiation modalities that offer promise in the field of head and neck radiation oncol-
ogy. Protons, which are positively charged particles in the nucleus, were initially
described by Ernest Rutherford in 1919 (Peake 1989). Decades of research ensued
before 1946 when Robert Wilson first proposed the use of protons as a potential new
tool in radiation oncology (Wilson 1946). The first patient was treated with proton
therapy at Berkeley Radiation Laboratory in 1954. After many years of clinical
investigation and refinement of proton beam technology, protons were first approved
by the FDA in 1988 (Smith 2009). The physical properties of protons result in a
dose distribution in the tissue with minimal exit dose beyond the prescribed depth.
This is particularly useful in the treatment of base of skull tumors, as its physical
characteristics allow for the delivery of curative doses of radiation despite close
proximity to structures with exquisite function such as the brainstem or optic chi-
asm. Today, proton therapy is under investigation for a variety of applications, and
its use is likely to be expanded as this data matures and the cost of this technology
declines.
As treatment delivery techniques have developed, the dose administered per frac-
tion has also been investigated. Conventionally, treatment is delivered in 1.8–2 Gy
per fraction (where 1 Gy refers to 1 joule per kilogram) with more fractions deliv-
ered to areas of higher risk for subclinical disease and the highest number of frac-
tions to gross tumor. Patients are typically treated 5 days a week, one treatment per
day in what is referred to as conventionally fractionated radiation. Hyperfractionation,
or the use of a greater number of smaller treatment doses, has been proposed as a
means of increasing total dose, and thus tumor control, without increasing perma-
nent toxicities from the radiation. The hyperfractionated approach has shown prom-
ise in head and neck cancers with the seminal EORTC trial published in 1992
showing a tumor control benefit in the treatment of oropharynx cancer (Horiot et al.
1992). Another novel approach is hypofractionation, involving higher doses per
fraction in fewer fractions. Hypofractionation has been used in a variety of cancer
types and has recently shown promise in the treatment of head and neck cancers.
Notably in 2006, there were noted improved outcomes using 2.25 Gy per fraction to
treat early-stage laryngeal cancer (Yamazaki et al. 2006). However, hypofraction-
ation in the head and neck region should be used with caution as this increases risk
of severe toxicity such as necrosis of the bone, cartilage, and soft tissues. Ongoing
clinical trials exist investigating the use of both hypofractionation and hyperfrac-
tionation to treat head and neck cancers.
248 B. H. Diamond et al.

5 Conclusion

Moving toward the future, the field of radiation oncology will continue to play an
integral role in the management of cancer. The foundations of modern radiation
oncology are a credit to the scientists and clinicians that have driven scientific prog-
ress allowing for radiotherapy to arise as a powerful clinical tool. Scientific progress
will undoubtedly continue to drive the field of radiation oncology forward building
upon its rich 130-year history.

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Head and Neck Tumor Surgery

Andrew Deek and Eric R. Carlson

1 Introduction

The practice of oral/head and neck tumor surgery represents an educational, techni-
cal, philosophical, and political transformation in the specialty of oral and maxil-
lofacial surgery. Once practiced by a select few interested and passionate individuals,
the subspecialty of oral/head and neck tumor surgery is now practiced by duly
trained individuals in the twenty-first century who claim justifiable legitimacy and
relevance with disruptive referral patterns and impressive clinical outcomes. The
specialty of oral and maxillofacial surgery was once supported by its membership
engaging in the routine diagnosis and occasional removal of benign and malignant
pathologic processes of the oral cavity, oropharynx, facial skin, and neck. Over
time, the development of bona fide and undisputed didactic and clinical blueprints
has defined the unique ability of qualified members of our specialty to provide com-
prehensive ablative and functional/aesthetic reconstructive surgery of the oral/head
and neck region while supporting patient safety (Carlson 2018).
The clinical repertoire of our specialty is perhaps best demonstrated in the inter-
national literature. It is true that we publish what we do, and our specialty’s trans-
formation is reflected in the literature that oral and maxillofacial surgeons have
historically published. To that end, one can peruse the four issues comprising the
first volume of the Journal of Oral Surgery in 1943 to appreciate the excitement of
our specialty’s membership for benign and malignant pathology of the oral/head
and neck region. Forty-eight papers were published in this first volume, 19 of which
focused on elements of pathology and tumor surgery of the oral and maxillofacial

A. Deek · E. R. Carlson (*)

Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center,
Knoxville, TN, USA
e-mail: [email protected]; [email protected]

© The Author(s), under exclusive license to Springer Nature 251

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_15
252 A. Deek and E. R. Carlson

region. By contrast, 15 papers focused on maxillofacial trauma diagnosis and man-

agement, part of our specialty’s core practice in 1943. A case report of metastasizing
ameloblastoma originating in the mandible and resulting in the death of a 27-year-
old patient is representative of the benign pathology discussed in this first volume of
the Journal of Oral Surgery (Schweitzer and Barnfield 1943). Other papers devoted
to the treatment of benign neoplastic disease by oral and maxillofacial surgeons
included those related to mixed tumors of the palate (Henny 1943; Wolfe and
Hubinger 1943). Four of the 19 pathology papers published in this first volume of
the Journal of Oral Surgery focused on malignant disease, including primary lym-
phosarcoma of the mandible (Penhale 1943), undiagnosed primary carcinoma of the
gingiva with disseminated metastases (Burket 1943), adenocarcinoma originating
from aberrant tissue in the gingiva (Loeb 1943), and carcinoma of the indifferent
cell type of the maxilla (Gunter et al. 1943). The latter two papers contained specific
comments regarding techniques of oncologic surgery, consistent with contemporary
approaches observed and executed in the twenty-first century.
Decades following publication of these initial papers in our specialty’s literature,
our subspecialty realized its genesis with subspecialty fellowship education, accred-
itation, certification, and research in the arena of oral/head and neck oncologic and
reconstructive surgery. Our subspecialty’s involvement in benign tumor surgery has
simultaneously evolved with recognition of evidence-based principles. The matu-
rity of our subspecialty in benign and malignant oral/head and neck tumor surgery
now represents a transformational and multidimensional process. This process has
involved not only focused clinical and didactic training as its requisite framework
but also precise and calculated national administrative oversight to effectively and
legitimately create this subspecialty and introduce it to the forefront of our spe-
cialty. The waning enthusiasm of competing specialties in the arena of head and
neck surgery, as well as the development of authentic training in this discipline
within oral and maxillofacial surgery, has formidably positioned members of our
specialty as the primary providers for patients with benign and malignant tumors of
the oral/head and neck region. What began as a vision of greatness for the clinical
care of patients with head and neck pathology in 1943 is now a well-recognized
subspecialty supported by formal fellowship training, excellence in accreditation
standards, board certification with a certificate of added qualifications, and an ongo-
ing commitment to clinical and didactic continuing education. Our specialty’s train-
ing and clinical appreciation for functional reconstruction of oral cancer patients, in
addition to our commitment to ablative surgery, represents the road map to compre-
hensive care for these patients.
A review of the complete process of our subspecialty’s development permits a
deep understanding of the mechanics of such creation in oral and maxillofacial sur-
gery. This chapter reviews this process in a dependent fashion of the development of
didactic and clinical competencies through formal medical education, general sur-
gery training, and fellowship training; accreditation of fellowship programs by the
Commission on Dental Accreditation; the formal recognition of the subspecialty
through the creation of dedicated committees within the American Association of
Head and Neck Tumor Surgery 253

Oral and Maxillofacial Surgeons; the establishment of the Certificate of Added

Qualification in oral/head and neck oncologic and reconstructive surgery by the
American Board of Oral and Maxillofacial Surgery; and the publication of our
research outcomes in the international oral and maxillofacial surgery literature.

2  arly Documents, Providers, Patients, and Essential

E
Ancillary Services

The first medical documents with references to malignant disease are the Ebers
Papyrus (Fig. 1), and the Edwin Smith Papyrus (Fig. 2). The Ebers Papyrus is a 110-­
page scroll written in hieratic Egyptian that measures approximately 20 meters in
length and is among the oldest preserved medical documents. The papyrus discusses
approximately 700 magical formulas and folk remedies, a treatise on the heart, a
review of depression and dementia, contraception, dentistry, and the surgical treat-
ment of abscesses and tumors. This voluminous record of ancient Egyptian medi-
cine is currently stored at the library of the University of Leipzig in Germany.
The Edwin Smith Papyrus is an ancient Egyptian medical text and the oldest
known treatise on trauma. The papyrus is a scroll written right to left in hieratic
Egyptian and measures approximately 15 feet in length. The papyrus represents a
surgical document discussing breast cancer, in part, and comprises 17 pages in
length. Collectively, the Ebers Papyrus and Edwin Smith Papyrus are primarily

Fig. 1 The Ebers Papyrus.

Accessed from www.
wikipedia.org, 20
Sept 2020
254 A. Deek and E. R. Carlson

Fig. 2 The Edwin Smith Papyrus. Accessed from www.wikipedia.org, 20 Sept 2020

devoted to issues of trauma and dated between 1600 and 1550 BCE, although they
contain descriptions of treatment from 3000 to 2500 BCE. According to the Ebers
Papyrus, an example of gingival cancer, like other cancers of the oral mucosa dis-
cussed in this Papyrus, was noted to have been treated by the Egyptians with cin-
namon, honey, and oil (Folz et al. 2008). Hippocrates (460–370 BCE) has been
cited as the first to mention the terms “carcinos” and “carcinoma” to describe clini-
cal conditions such as ulcerative and non-ulcerative tumors (Carlson 2018; Folz
et al. 2008). He recommended the treatment of cancer with caustic pastes and cau-
tery, and he recommended nonsurgical approaches to deeply invasive cancers, an
approach that soon became known as the Doctrine of Hippocrates.
Aulus Cornelius Celsus (25 BCE–50 CE) has been cited as the first head and
neck surgeon who described a surgical procedure for cancer of the lower lip in his
medical text De Medecina (Goldstein and Sisson 1996). Although Celsus utilized
the terms “carcinode” and “carcinoma,” he recommended against the surgical treat-
ment of cancer. Microscopic confirmation of the presence of cancer was first estab-
lished in 1885 when Dr. George Elliott initiated interest in histopathology in his
description of President Grant’s cancer of the tonsil and tongue base (Carlson 2002;
Goldstein and Sisson 1996). Surgery was never performed on Grant although the
opinion of New York surgeon, Dr. George Shrady, was sought, and a radical surgical
procedure was thought to be a reasonable approach for the former president.
Moreover, radiation therapy was not considered a modality of treatment at that time.
Grant resorted to sleeping upright after an initial episode of threatened suffocation.
A severe hemorrhagic event and expectoration of part of the cancer relieved his
partial airway obstruction although Grant died of his disease some 13.5 months fol-
lowing its original diagnosis.
Head and Neck Tumor Surgery 255

3 Histopathology

The use of histopathology as part of diagnostic biopsies prior to cancer surgery was
popularized in 1893 in the case of sitting US President Grover Cleveland, when
incisional biopsies of his palatal lesion were procured by White House physician
Major Robert Maitland O’Reilly. The diagnosis was thought to be consistent with
squamous cell carcinoma, although some believe that the prognostically more
favorable verrucous carcinoma was a more likely diagnosis. The microscopic diag-
nosis of President Cleveland’s tumor was offered by Dr. William Welch from Johns
Hopkins Hospital (Goldstein and Sisson 1996). This diagnosis occurred during a
time of economic ruin in the United States such that President Cleveland’s diagnosis
and treatment were issues of national security. On June 30, 1893 President Cleveland
boarded the Oneida, a yacht that was owned by Commodore Elias C. Benedict,
along with Dr. Joseph Bryant, an eminent general surgeon of the day, who had pre-
viously published a history of 250 cases of maxillary resection, only two of which
he personally performed. Providing assistance for the maxillary resection was neu-
rosurgeon Dr. William Keen, and dentist Dr. Ferdinand Hasbrouck was assigned to
the performance of necessary dental extractions and the administration of anesthe-
sia. Dr. Edward Janeway, Dr. O’Reilly, and Dr. JF Eidmann, who assisted Dr.
Bryant, were also present for the surgical procedure. The slightly longer than 1-h
July 1, 1893 surgery was successful, and President Cleveland recovered from sur-
gery and anesthesia aboard the Oneida that docked in Buzzards Bay. Shortly there-
after, Dr. Kason Gibson, a dentist, afforded the president with a vulcanized rubber
obturator that permitted President Cleveland to address a session of Congress on
August 7, 1893, only 5 weeks postoperatively. Cleveland passed away in June 1908,
some 15 years following his cancer operation and at a time when he was undoubt-
edly cured of his disease.

4 Frozen Sections

The work of Christian Nezelof in frozen sections, later popularized by Dr. Thomas
Cullen, further legitimized the value of microscopic tissue examination as part of
tumor surgery and ushered in the routine evaluation of tissue as standard practice
(Folz et al. 2008). In 1891, Dr. William Welch at Johns Hopkins Hospital used a
carbon dioxide freezing microtome in the analysis of breast tissue removed by Dr.
William Halstead (Gal 2005). As dictated by history, the frozen section analysis was
excessively long for Dr. Halstead’s preference such that the surgical procedure was
completed before the results of the frozen sections were available. Dr. Cullen is
credited with the first publication on the frozen section technique. The subsequent
work of Dr. Louis B. Wilson of the Mayo Clinic ultimately ushered in a technique
that is largely indispensable in contemporary cancer surgery, including that per-
formed in the oral/head and neck region.
256 A. Deek and E. R. Carlson

5 Antibiosis and Anesthesia

Advances in antibiosis and anesthesia represented new vistas for the practice of
oral/head and neck surgery in the nineteenth century. The introduction of general
anesthesia by Horace Wells and William Thomas Green Morton resulted in Dr. John
Warren, a celebrated professor of surgery at Harvard Medical School and its dean,
removing a tumor of the neck from Edward Gilbert Abbot. The patient was anesthe-
tized with ether by Dr. Morton in a public demonstration at the yet to be named
Ether Dome at Massachusetts General Hospital on October 16, 1846 (Fig. 3). When
the patient emerged from anesthesia and indicated that he had felt no pain, Dr.
Warren indicated that “this is no humbug.” This successful surgical procedure
exemplified the essential nature of anesthesia in the practice of oral/head and neck
ablative surgery and surgery, in general (see Chapter “Anesthesia”).

Fig. 3 Neck tumor surgery performed in 1846 at Massachusetts General Hospital by Dr. John
Warren with administration of ether anesthesia by Dr. William Thomas Green Morton for patient
Edward Gilbert Abbot. (Accessed from https://www.google.com/search?q=the+ether+dome+surg
ery&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjknNqWnKzUAhUCPiYKHfPhCaEQ_
AUIBigB&biw=1280&bih=899#imgrc=_&spf=1496855210893, 20 Sept 2020)
Head and Neck Tumor Surgery 257

6  aradigm Shift in Surgical Management of Oral/Head

P
and Neck Cancer

The published works of George Crile (Fig. 4) in 1905 (Crile 1905) and 1906 (Crile
1906) represented a paradigm shift in the surgical management of oral/head and
neck cancer, specifically related to isolated local surgery. As part of the acknowl-
edgment of treatment failures in patients treated in the late nineteenth century, Crile
advocated that surgical management of oral/head and neck cancer ought to consist
of removal of the primary cancer as well as all associated cervical lymph nodes,
including those that were visibly enlarged and/or palpably enlarged (Fig. 5). He
emphasized that palpable cervical lymph nodes may be inflammatory and impal-
pable lymph nodes may contain cancer. He stressed that excision of a primary focus
only of cancer in the head and neck region without addressing the regional lym-
phatic system represented an incomplete dissection and would provoke the dissemi-
nation of growth of the cancer. Crile indicated that incomplete operations do more
harm than good. He therefore developed a technique for neck dissection that resulted
in minimal hemorrhage and infection while removing all lymph nodes in the ipsilat-
eral neck of patients with N+ necks and a more conservative approach to neck

Fig. 4 Dr. George Crile

(1864–1943). (Accessed
from https://www.facs.org/
about-­acs/archives/
pasthighlights/
crilehighlight, 20 Sept
2020)
258 A. Deek and E. R. Carlson

a b

c d

Fig. 5 A 60-year-old man presented with a 4-month history of a mass of the left neck (a). Physical
examination revealed a mass of the left palatine tonsil (b). A diagnosis of squamous cell carcinoma
of the left cervical lymph node was proposed based on fine needle aspiration biopsy. The CT
images demonstrate the left tonsillar mass (c) and the enlarged and partially necrotic lymph node
in level II of the left neck (d). The patient underwent left tonsillectomy (e) that identified squamous
cell carcinoma on frozen sections. A left type I modified radical neck dissection was performed (f,
g). Metastatic squamous cell carcinoma was identified in two of 62 lymph nodes in the left neck
dissection specimen. The patient underwent postoperative radiation therapy and was without evi-
dence of disease in the left neck (h) and tonsillar bed (i) at 6 years postoperatively. Patient consent
obtained to publish his facial photographs without blocking out his eyes
Head and Neck Tumor Surgery 259

e f

g h

Fig. 5 (continued)
260 A. Deek and E. R. Carlson

dissection in patients with N0 necks. Crile reported on 132 such operations, the last
63 of which were properly classified as N+ or N0. Thirty-one cases were identified
as cancers of the lips, and 12 cases were reported in the tongue. With his technique,
Dr. Crile decreed that since the regional lymphatics of the head and neck are acces-
sible, applying the same comprehensive block dissection as utilized in breast can-
cer, the final outcomes in head and neck cancer should yield better results than
cancer surgery of other anatomic regions of the body. Dr. Crile and his discussants
emphasized the need to avoid handling the cancer during ablative surgery to reduce
the dissemination of disease, a point further discussed in his 1923 paper (Crile 1923).
The terminology composite operation was first thoroughly discussed by Grant
Ward in 1959 based on his first case performed in 1932 (Ward et al. 1959). Dr. Ward
selected this term as it was felt to protect the humanity of the patient, rather than
suggesting an assault on the patient or reflecting a dishonorable attitude by surgeons
as might have been considered with the term, commando operation (Ward et al.
1959). In addition, this terminology exemplified the en bloc nature of the dissection.
Ward published his series of 577 patients with oral cavity cancer exclusive of lip
cancer operated between 1946 and 1958 including 453 patients treated by compos-
ite operation. He reported an overall 3.9% (18 cases) mortality in his series. This
included one operative death with the enduring patients dying from any cause within
3 months of the operation. The 3-year survival rate was 51% and the 5-year survival
rate was 35.5%.
In 1951, Hayes Martin (Fig. 6) et al. (1951) published a 59-page monograph on
neck dissection that included his experience with 665 cases in 599 patients from
1928 to 1945. In this paper, radical neck dissection was defined as an en bloc resec-
tion of lymph nodes from inferior border of the mandible to clavicle along with the
sternocleidomastoid muscle, submandibular gland, and internal jugular vein. No
discussion of the spinal accessory nerve was offered by the authors. The radical
neck dissection was distinguished from the partial neck dissection that involved
excision of structures in the submandibular and supraomohyoid regions or the bilat-
eral submental regions. The authors included outcomes from 144 tongue cancers,
the most common anatomic site in the series, 127 cases of which corresponded to
25% of the 500 clinically positive necks on presentation. The 144 cases of tongue
cancer were operated with 13 bilateral neck dissections and 131 unilateral neck dis-
sections. It is noteworthy that Martin offered indications for neck dissection in this
paper. Among them included definite clinical evidence that cancer was present in
the cervical lymphatics, the primary lesion giving rise to the metastasis was con-
trolled clinically either prior to or at the same time as the neck dissection, a reason-
able chance existed of complete removal of the cervical metastases, the lack of
clinical or radiographic evidence of distant metastases existed, and the neck dissec-
tion offered a greater chance of cure than radiation therapy. Remarkably, the author
defined prophylactic neck dissection as a separate and independent procedure, not
in conjunction with excision of the primary cancer, in patients for whom the pri-
mary cancer had already been surgically addressed.
Head and Neck Tumor Surgery 261

Fig. 6 Dr. Hayes Martin

(1892–1977). (Accessed
from https://www.ahns.
info/about-­ahns/past_
presidents/martin/, 20 Sept
2020)

7 The Society of Head and Neck Surgeons

In 1954, Drs. Martin and Ward conceived the Society of Head and Neck Surgeons.
Most of the society’s membership was general surgeons or plastic surgeons, sym-
bolic of the involvement of these surgeons in this subspecialty practice at that time.
Many members had additional training in surgical oncology. In 1957, six otolaryn-
gologists developed an organization composed primarily of otolaryngologists with
an interest in head and neck surgery that became known as the American Society for
Head and Neck Surgery in 1959. The first president was Dr. John Conley, and the
society’s mission was, in part, to encourage the training of otolaryngology residents
in head and neck surgery. Specifically, it was this organization’s goal to enable and
advance knowledge relevant to surgical treatment of diseases of the head and neck,
including reconstruction and rehabilitation; promote advancement of the highest
professional and ethical standards as they pertain to the practice of major head and
neck surgery; and to honor those who have made major contributions in the field of
head and neck surgery or have aided in its advancement. In 1968, Dr. William
262 A. Deek and E. R. Carlson

McComb, president of the Society of Head and Neck Surgeons, engaged a commit-
tee to investigate the educational training of head and neck surgeons. In December
1968, a similar committee appointed by the American Society for Head and Neck
Surgery met in Pittsburgh. In October 1974, the Training Committee of the Society
of Head and Neck Surgeons developed a course curriculum for fellowship training.
In December 1975, a joint meeting of the Head and Neck Training Committee of the
two head and neck societies was held in Chicago, and this combined training com-
mittee refined the course curriculum for training head and neck oncologic surgeons.
This committee is contemporarily known as the Joint Council for Approval of
Advanced Training in Head and Neck Oncologic Surgery. The course curriculum
developed by this committee was approved by the Society of Head and Neck
Surgeons in 1976 and by the American Society for Head and Neck Surgery in 1977
(Shah 1991). In 1998, the existence of two societies devoted to the same discipline
was thought to be duplicative, such that the two societies merged into the American
Head and Neck Society whose mission was to provide a unified voice to the advance-
ment of research and education in head and neck oncology. This society remains
dedicated to the common goals of its parent organizations. The International
Federation of Head and Neck Oncologic Societies (IFHNOS) was established in
1987 with the purpose of creating channels of communication to enhance exchange
of information, improve knowledge, and explore new directions in management of
patients with head and neck cancer (Folz et al. 2008). Dr. Jatin Shah (Fig. 7) of
Memorial Sloan Kettering Cancer Institute in New York conceived the idea of such

Fig. 7 Dr. Jatin Shah

(1941). (Accessed from
https://www.ahns.info/
about-­ahns/past_
presidents/shah/, 6 Jun
2017)
Head and Neck Tumor Surgery 263

an international body bringing together specialists involved in the care of patients

with head and neck cancer worldwide. A steering committee was formed and met in
London on May 1, 1987, with representation of 16 head and neck organizations
from North America, South America, Europe, Africa, and Asia. The steering com-
mittee drafted the constitution and bylaws of the Federation that was subsequently
ratified by the Governing Council, consisting of one member from each member
organization in the Federation. The Federation has grown since its establishment,
with a membership of 43 head and neck oncologic organizations, representing 65
countries. Quadrennial World congresses of the Federation have taken place since
1998. In recognition of his tremendous contributions to head and neck surgery, the
IFHNOS has established the Jatin Shah lecture at its world congresses.

8  isruptive Innovation: Enter Oral

D
and Maxillofacial Surgery

The previous discussion serves to describe the organization of two societies in head
and neck surgery and ultimately a single, unified society. While their specific edu-
cational objectives were unclear, including the existence of any accreditation stan-
dards, their voice was clearly heard. The Joint Council for Approval of Advanced
Training in Head and Neck Oncologic Surgery was established in 1977 under the
direction of Dr. John Lore, Jr. The Council was thereafter known as the Joint
Training Council, and its objectives were to establish a program review process to
create well-structured training programs with a specified didactic curriculum. The
clinical influence of general surgeons and otolaryngologists in the management of
patients with head and neck cancer was apparent. This notwithstanding, before and
during this time, three oral and maxillofacial surgeons shared a career-long passion
for oral cancer surgery, including Drs. Elmer Hume, Fred Henny, and Claude
LaDow (Dierks 2002). These three individuals were passionately supportive of oral
and maxillofacial surgery and trained future clinical and academic leaders of our
specialty. Dr. Hume, who lived to the age of 98 years, was chairman of the
Department of Oral Surgery at the Louisville College of Dentistry, later named the
University of Louisville. He shared an office with his brother, a general surgeon,
and later became chief of Maxillofacial Surgery at St. Joseph’s Hospital in Louisville
where he conducted an oral cancer clinic with his partner, Dr. James Skaggs. Dr.
Hume frequently performed jaw resections, glossectomies, and orbital exentera-
tions. Cases that involved a neck dissection were performed as a team effort with
general surgery with Drs. Hume and Skaggs performing the ablative and reconstruc-
tive surgery of the primary cancer. Dr. Fred Henny became the chief of Oral Surgery
at Henry Ford Hospital in 1952 and developed his institution as a referral center for
the surgical management of oral cancer. During his 18-year administrative and clini-
cal roles at Henry Ford Hospital, Dr. Henny became known for his educational and
clinical prowess, training future leaders of our specialty, including Drs. Guy Catone,
264 A. Deek and E. R. Carlson

Bruce Epker, William Grau, Bruce MacIntosh, and Ralph Merrill. Dr. LaDow
served as chairman of the Department of Oral Surgery at the University of
Pennsylvania from 1952 to 1974. He received formal training in head and neck
surgery by Dr. John Gunter in Philadelphia and was involved in extensive head and
neck surgical procedures under Dr. John Dorrance. Dr. LaDow served as chief of
Oral Surgery at Episcopal Hospital in Philadelphia in the 1950s, and he also per-
formed surgery at the American Oncologic Hospital of Philadelphia during that
time. Dr. LaDow’s comprehensive dedication to oncology was seen in his interest in
placing radium needles and radon seeds into head and neck malignancies (LaDow
1984). He also placed carotid artery catheters through the superficial temporal artery
for the intratumoral delivery of chemotherapy. The clinical presence of Drs. Hume,
Henny, and LaDow established a reputable clinical base in oral/head and neck can-
cer surgery for the specialty of oral and maxillofacial surgery. Their strong leader-
ship presence provided very favorable exposure of the specialty of oral and
maxillofacial surgery in the management of patients with oral cancer. That notwith-
standing, the 1960s ushered in changes in the practices of these surgeons due to the
development and strategic vision of the two previously mentioned head and neck
organizations that ultimately unified. In addition, the emphasis of oral and maxil-
lofacial surgery changed during this time, in part due to the fascination that was
developing in orthognathic surgery. Nonetheless, the establishment of oral/head and
neck oncologic surgery fellowship programs by Dr. Robert Marx at the University
of Miami in 1985 and by Dr. Eric Dierks at Legacy Emanuel Hospital in Portland,
Oregon, in 1992 would lead to newfound enthusiasm for the development of sub-
specialty training in oral/head and neck oncologic and reconstructive surgery.
Similar clinical and educational initiatives were established by Dr. Robert Ord at the
University of Maryland in 1989 and Dr. Joseph Helman at the University of
Michigan in 1994. Fellowships, once referred to as the third wave in oral and maxil-
lofacial surgery, have been described as a contemporary mechanism that surgical
specialties use to advance the art and science of their disciplines (Assael 2009a).
They can be thought of as formal consolidation of clinical and educational tools to
advance the art and science of a surgical discipline that became legitimized. The
development of fellowships as the background of our subspecialty has been
described as necessary to the future success of oral and maxillofacial surgery
(Assael 2009a).
In 2001, Dr. Jesus Medina delivered his American Head and Neck Society
Presidential address entitled “Tragic optimism vs learning on the verge of more
change and great advances” (Medina 2001). As part of this address, Dr. Medina
recognized the change that was inevitable in the practice of medicine, yet he empha-
sized the recent acceleration and greater change that was being observed at that
time. Specifically, Medina mentioned the cost and reimbursement of head and neck
surgical procedures, providing his forecast for medicine that the value for surgical
services will be defined as the quality of surgical outcomes divided by their cost. In
addition, Medina expressed concern for the decline in the number of applicants to
head and neck fellowships, citing the number of general surgery residents consider-
ing head and neck surgery to be minimal. Shah (2005) further cited the insufficient
Head and Neck Tumor Surgery 265

job opportunities for head and neck surgeons and limited patient volumes account-
ing for the declining interest in these fellowship programs that would otherwise
support a career in this discipline. In response to unfavorable pressures in the provi-
sion of head and neck surgical care to patients, Medina indicated that working
harder to be successful in the subspecialty of head and neck surgery could lead to
one or more preventable tragedies, including the bankruptcy of one’s practice, the
abandonment of head and neck oncologic surgery to practice more lucrative surgi-
cal procedures, or forfeiting one’s role as a patient advocate. Lest the members of
his specialty accept their call to action, tragic optimism might be the most applica-
ble label of the ambivalence that might otherwise exist. The response of this pub-
lished pessimism by the specialty of oral and maxillofacial surgery can only be
called strategic opportunism (Carlson 2014) and what followed can only be referred
to as a renaissance. Unambiguously, the clinical groundwork laid in oral/head and
neck oncologic surgery by Drs. Hume, Henny, and LaDow, as well as the fellowship
training programs of Drs. Marx and Dierks, was administratively supported by fel-
lowship program accreditation and individual subspecialty certification that would
follow. Collectively, every element of this surreptitiously calculated process is remi-
niscent of the business concept, disruptive innovation. Disruptive innovation
describes a process where a previously considered inferior entity can challenge
incumbent entities, specifically those controlling a market share of the industry
under consideration. As stated by Christensen et al., as incumbent entities concen-
trate on improving their services for their most demanding customers, they exceed
the requirements of some customers and ignore the needs of others (Christensen
et al. 2009; Christensen et al. 2015). Entities that realize disruptive innovation initi-
ate their process by addressing overlooked customers and their overlooked needs.
The incumbents, chasing higher profitability in more demanding segments, tend to
be slow or denying in their response, incorrectly believing that their momentum and
stronghold on the market will forever be unencumbered. According to Christensen
et al., disruptors then move upmarket, delivering the performance that the customers
of incumbents require while also preserving the advantages that created their early
success (Guralnick 1973).

9  ix-Year OMFS/MD Residency Programs and General

S
Surgery Training

In 1973, Dr. Walter Guralnick (Fig. 8), then professor and chairman of the
Department of Oral Surgery at the Harvard School of Dental Medicine and chief of
Oral Surgery at Massachusetts General Hospital, published his philosophy and
ethos regarding a transformation of the educational process in our specialty
(Guralnick 1973). Dr. Guralnick pointed to the educational deficit that he recog-
nized in our specialty’s training programs, specifically that our residency programs
consisted of insufficient medical and surgical training. In addition to high-quality
oral surgical training, Dr. Guralnick believed that such deficits could be remedied
266 A. Deek and E. R. Carlson

Fig. 8 Dr. Walter

Guralnick (1917–2017).
(Personal collection
of ERC)

by residents obtaining a medical degree as well as general surgical training. He cited

the sentiment of Dr. James Hayward at the time who indicated that two essential and
complex requirements of oral surgery training in that era were to educate the educa-
tors of our specialty’s needs while also gaining the respect of physician colleagues.
Moreover, Guralnick considered the comments of General Robert Shira who indi-
cated that while the medical degree would reduce administrative problems that were
encountered by some members of our specialty in the 1970s, the added education
would not improve the individual’s surgical proficiency. Dr. Shira concluded that
the addition of the MD, while imparting broad educational advantages, would not
justify the added time and expense to obtain such education.
In his original paper, Dr. Guralnick disclosed the value-added nature of members
of our specialty obtaining their medical degrees, specifically, their ability to also
obtain general surgical training. He pointed to the renaissance in our specialty, as
well as the leaders and innovators of this period who were oral surgeons who pos-
sessed general surgical training as well as oral surgery training. Guralnick elabo-
rated that general surgery training would prepare the resident to care for the “whole
patient.” This educational process would permit the oral surgery resident to be able
to perform equivalently to those in other surgical specialties, particularly regarding
properly trained oral surgeons being able to manage the patient’s care in the inten-
sive care unit, perform a tracheotomy, remove a rib for reconstructive purposes, and
ligate the external carotid artery. In the final analysis, three benefits would develop
Head and Neck Tumor Surgery 267

from such a dual degree training program. First, the expanded didactic and clinical
curriculum would be beneficial to the overall education of the oral surgery resident.
Second, oral surgery residents would be educationally qualified to serve as general
surgery residents, thereby permitting the application of principles of medicine
learned in medical school. Finally, graduates of the dual degree program would
enter the mainstream of surgical specialists and narrow the political gap that fuels
turf battles among competing surgical specialists. No mention was made of the
benefits of the medical degree and general surgery training in permitting the resi-
dent to secure fellowship training in oral/head and neck oncologic and reconstruc-
tive surgery and to confidently care for compromised patients with neoplastic
disease of this region.
With approval from the administrative board at the Harvard Medical School, the
first student entered the program and graduated Harvard Medical School in 1972. In
so doing, this first student’s curriculum involved the first 3 years of the current den-
tal curriculum of which the first 1.5 years were spent in the medical school complet-
ing the preclinical basic science curriculum with the medical students and the
second 1.5 years involved the dental curriculum at the School of Dental Medicine.
An oral surgery internship comprised the fourth year of the program followed by the
principal clinical year at the medical school and its teaching hospitals. Thereafter,
6 months were spent as a resident in oral surgery and 6 months were spent as a gen-
eral surgery intern. The seventh year of the program involved a general surgery year
and the eighth year of the program involved an oral surgery year. In all, the 8-year
program involved 2.5 years spent in medical school, 1.5 years were spent in dental
school, 2.5 years were spent on the clinical oral surgery service, and 1.5 years were
spent on the clinical general surgery service.
As should have been anticipated, the educational change implemented by the
Harvard program was met with relative outcry, skepticism, and reported controversy
within dentistry and oral surgery. In 1972, Dr. Morton Goldberg expressed his con-
cerns with the new curriculum, indicating that our specialty was erroneously rush-
ing onto an illusionary, exhausting, and self-destructive course in search of parity
with other surgical specialties (Goldberg 1972). His letter to the editor generally
represented a pessimistic discourse on the Harvard plan. This notwithstanding,
Goldberg lamented that experimentation is necessary in science, even in the “sci-
ence” of education. He concluded his letter to the editor by stating that the resi-
dency/MD programs represented a potential answer to our problems. Such programs,
he stated, were short, inexpensive, educationally sound, and hopefully would be
equally acceptable to organized oral surgery and the medical establishment. In ret-
rospect, Dr. Goldberg indicated that his 1972 published statement was incorrect
(personal communication, May 25, 2017). He now believes that double-degree edu-
cation has not split our specialty. His experience and opinion with the general sur-
gery year remains correct, per Dr. Goldberg. Greater than four decades later, he
believes that the general surgery experience does not represent 1 year of retractor
holding for carotid surgery, appendectomies, herniorrhaphies, etc., but a year of
studying surgical metabolism, fluid-electrolyte balance, tissue healing, and general
surgical principles. Thus, the general surgery experience provides caring for the
268 A. Deek and E. R. Carlson

whole patient, including their concerns, fears, and families, and that serious illness
is a two-way street. Such general surgery experiences can properly prepare the resi-
dent for fellowship training in oral/head and neck oncologic and reconstructive sur-
gery. As an example, lessons from the cancer ward include the essential nature of
empathy and compassion in the management of sick patients, and these qualities
ought to be reinforced during general surgical training and practiced during fellow-
ship training (Assael 2008).
In 1972, Eisenbud presented an analysis of the potential impact of oral surgery-
­MD programs before the Section on Oral Surgery, Anesthesia, and Hospital Dental
Service at the American Association of Dental Schools (Eisenbud 1973). From the
perspective of turf battles, Eisenbud suggested that this new curriculum would cre-
ate even greater conflict for the oral surgeon. He indicated that rather than express-
ing concern at the absence of the MD degree, the plastic surgeons would point to the
absence of plastic surgery training and the head and neck surgeon to the absence of
head and neck surgery training. He pointed out that such programs would produce
a synthetic teratism: too good to extract teeth and not good enough to perform a
radical neck dissection. Eisenbud was decades ahead of his time as future educa-
tional thought leaders in oral and maxillofacial surgery would create a solution to
his perceived problem by creating fellowship programs in our subspecialty such that
trainees would be good enough to perform a radical neck dissection.
In 2004, Dodson et al. (2004) provided a 30-year review of the Massachusetts
General Hospital/Harvard Medical School Oral and Maxillofacial Surgery/MD
Program. This retrospective cohort study assessed the outcomes of 56 graduates of
the program from 1971 to 2000, specifically with regard to successful completion of
the dual-degree program, performance on steps I and II of the US Medical Licensing
Examination/National Board of Medical Examinations (USMLE/NBME), Harvard
Medical School grades, and career trajectories such as full- or part-time academic
practice or private practice. Of the 56 individuals who entered the combined pro-
gram, all graduated from Harvard Medical School. Four individuals did not com-
plete the OMFS portion of the combined program and chose non-OMFS career
paths. Three graduates of the combined program completed additional specialty
training, one in plastic surgery and two in otolaryngology. One of the 56 graduates
of the program in this cohort entered fellowship training in oral/head and neck
oncologic and reconstructive surgery, and two additional residents completed such
fellowship training thereafter.
The introduction of formal medical school in oral and maxillofacial surgery
training that leads to general surgery training is arguably one of the greatest contro-
versies in the history of our exemplary specialty. No doubt, many of the pioneers of
our specialty were singularly qualified, and their hard work and exceptional out-
comes created an international level of respect and admiration for all members of
our specialty. In addition, the technical expertise of members of our specialty was
clearly derived from oral and maxillofacial surgery training rather than formal med-
ical training. This notwithstanding, the Guralnick plan supports the training of those
members of our specialty wishing to practice oral/head and neck tumor and recon-
structive surgery at its highest level, the ability to do so resulting in part from their
Head and Neck Tumor Surgery 269

obtaining general surgery training. There are two obvious reasons that support this
statement. First, as stated by Dr. Goldberg in 1972, he had never been questioned as
to why his oral surgery colleagues did not possess an MD, but he was frequently
asked why oral and maxillofacial surgery was the only surgical specialty where resi-
dents were not given a basic year of general surgery training. Fast forwarding to the
twenty-first century, it is clear anecdotally and experientially proved that the general
surgery year is invaluable in terms of being able to effectively and confidently
assume daily care for sick patients for whom fellowship trained oral/head and neck
oncologic and reconstructive surgeons are responsible. Second, medical school
training followed by general surgery training overcomes a relatively deficient,
abbreviated, and impractical medical curriculum in dental school. The dental gradu-
ate who enters a high-quality, accredited, and full-scope oral and maxillofacial sur-
gery residency program will be afforded a valuable clinical education. Such a
resident will undoubtedly benefit from the off-service experience on internal medi-
cine, general surgery, and elective medical rotations. That said, there is no substitute
for the full medical education that is afforded to residents in 6-year oral and maxil-
lofacial surgery residency programs where full integration in comprehensive medi-
cal curricula occurs, leading to the MD degree, followed by a 1-year experience in
general surgery. While this statement remains controversial after decades of
recorded discussion and healthy debate, the value of the MD curriculum and general
surgery training is undoubtedly meaningful and relevant to the individual wishing to
practice our subspecialty at the highest level.

10 Accreditation by the Commission on Dental Accreditation

The Commission on Dental Accreditation (CODA) was established in 1975 and

remains recognized by the US Department of Education. From 1938 to 1974 the
Council on Dental Education of the American Dental Association was the accredit-
ing organization for dental and dental-related education programs. In 1972, the
Council recognized the need to provide the communities of interest with greater
representation in accreditation policy issues and decisions such that CODA was
ultimately established. Prior to formal accreditation of oral/head and neck onco-
logic and reconstructive surgery fellowship programs, the American Association of
Oral and Maxillofacial Surgeons (AAOMS) conducted site visits of existing fellow-
ship programs for recognition of the educational quality of these programs begin-
ning in 1996. This fellowship recognition process occurred due to the realization of
the lack of accrediting body status by the AAOMS. This led to the AAOMS
approaching CODA, an approved accrediting body by the US Department of
Education, concerning their willingness to assume responsibility for accrediting fel-
lowship programs in oral and maxillofacial surgery. There was initial concurrence,
in principle, that the Commission should assume such responsibility. The
Commission first adopted proposed Accreditation Standards for Clinical Fellowship
Training in Oral and Maxillofacial Surgery in January 1997 that included oral/head
270 A. Deek and E. R. Carlson

and neck oncologic and reconstructive surgery fellowships. At that time, the imple-
mentation date was planned for January 1999. After having circulated among the
communities of interest for comment beginning in 1997, the Commission finally
adopted and implemented the Accreditation Standards for Clinical Fellowship
Training Programs in Oral and Maxillofacial Surgery on January 1, 2000.
Fellowship accreditation represents a voluntary process that ensures fellows,
specialty boards, and the public that the training program follows published stan-
dards. Annual programmatic data from fellowship program directors and site visitor
reports provides CODA the opportunity to establish accreditation actions. The Oral
and Maxillofacial Surgery Review Committee, comprised of the Oral and
Maxillofacial Surgery Commissioner as well as educators within our specialty
appointed by the AAOMS and the ABOMS, provides administrative oversight of the
accreditation process with the Commissioner reporting to the Commission the
accreditation recommendations of the review committee. The Commission has the
ultimate decision regarding a fellowship program’s accreditation status. The
Commission’s primary objective in the accreditation of oral/head and neck onco-
logic and reconstructive surgery fellowship programs is to ensure that comprehen-
sive clinical and didactic training is provided to fellows that will enable these
individuals to serve as primary oral/head and neck oncologic and reconstructive
surgeons in a cancer team following training.
In 2020, 14 institutions (Table 1) conduct fellowship programs in oral/head and
neck oncologic and reconstructive surgery. Nine of these fellowships exist within
academic oral and maxillofacial surgery departments that directly sponsor accred-
ited residency programs. These fellowship programs are 12–24 months in length
and offer fellows a comprehensive training in the management of oral and oropha-
ryngeal tumors and microvascular surgery (Kademani et al. 2016). These programs
originally participated in the maxillofacial oncology and reconstructive surgery
match service (MORS match, https://www.MORSmatch.com) established in 2013.
Effective in 2019, the fellowship match occurs in the American Academy of
Craniomaxillofacial Surgeons (www.aacmfsmatch.org). The demand for oral/head
and neck oncologic and reconstructive surgery fellowship programs remains robust
as the number of applicants to these fellowship programs exceeds the number of
available positions such that several candidates in the match process each year are
not successful in securing a fellowship position (Table 2).
The recruitment of oral and maxillofacial surgeons into oral/head and neck onco-
logic and reconstructive surgery fellowships is intuitive. Such trainees are comfort-
able with bone plating; the management of soft tissues in the oral cavity, face, and
neck; and the resection of the bone (Assael 2008). Moreover, these fellows possess
proficiency in the principles of occlusion, arch form of the jaws, and orofacial func-
tion that lends to a unique understanding of orofacial reconstruction. Such fellows
assume care for a patient with a benign or malignant tumor of the oral/head and
neck region, provide effective resection with surgical management of cervical
metastases, reconstruct the defect with a variety of flaps, and place implants in bone
grafts, thereby providing comprehensive care for these patients whose ability to be
functionally reconstructed is greatly enhanced (Hupp 2011).
Head and Neck Tumor Surgery 271

Table 1 Oral/head and neck oncologic surgery fellowship programs in the United States in 2020
Date of most
Program Date recent
Program director in 2020 Location established accreditation
John Peter Smith Fayette Ft. Worth, Texas 2014
Hospital Williams, DDS,
MD
Louisiana State David Kim, Shreveport, 2006 2015
University DMD, MD Louisiana
Minnesota Head and Deepak Minneapolis, 2020
Neck Surgery Kademani, Minnesota
DMD, MD
North Memorial Hospital Ketan Patel, Minneapolis, 2012 2017
and Humbert Humphrey DDS, PhD Minnesota
Cancer Center
University of Alabama Anthony Birmingham, 2016
Morlandt, DDS, Alabama
MD
University of Florida Rui Fernandes, Jacksonville, 2008 2015
College of Medicine DMD, MD Florida
University of Maryland Joshua Lubek, Baltimore, 1989 2018
DDS, MD Maryland
University of Miami Ramzey Tursun, Miami, Florida 1985
DDS
University of Michigan Brent Ward, Ann Arbor, 1994 2018
DDS, MD Michigan
University of Tennessee Eric Carlson, Knoxville, 2009 2017
DMD, MD, Tennessee
EdM
University of California Brian Woo, Fresno, 2018
DDS, MD California
University of Texas Jonathan Shum, Houston, Texas 2016
Health Science Center DDS, MD
Boston University Andrew Boston, 2011 2025
Salama, DMD, Massachusetts
MD
Providence Portland R. Bryan Bell, Portland, 2019 2020
Medical Center DDS, MD Oregon

11  he American Association of Oral

T
and Maxillofacial Surgeons

In 2008, then American Association of Oral and Maxillofacial Surgeons president,

Dr. W. Mark Tucker, established the Oral Cancer Task Force to assist in our spe-
cialty’s management of patients with oral cancer. Under the leadership of Dr. Paul
Lambert, the task force was charged with improving oral cancer care in the United
States with three primary objectives: (1) to provide educational recommendations to
272 A. Deek and E. R. Carlson

Table 2 The number of oncologic surgery fellowship programs and the number of applicants to
these programs
Number of institutions participating in
the match (number of available Number of candidates submitting
Year positions) rank lists for the match
2013 7 8
2014 8 14
2015 7 13
2016 7 15
2017 7 17
2018 6 14
2019 10 18
2020 10 16
The competitive nature of these programs is noted with the number of applicants exceeding the
number of available positions each year. Unmatched applicants have been realized due to the com-
petitive nature of this process

the AAOMS Board of Trustees, (2) to realize the development of additional fellow-
ship programs, and (3) to identify and support strategic areas of clinical and basic
science research in oral cancer (Kademani et al. 2008). Such research findings were
encouraged to be submitted to the Journal of Oral and Maxillofacial Surgery, Oral
Oncology, and Head and Neck for consideration of publication. In June 2007 the
Board of Trustees of AAOMS made the following recommendations and amend-
ments to their strategic plan 2005–2008 by the third quarter of 2008, including the
creation and dissemination of an oral cancer evaluation and treatment module for
the National Curriculum Database; the development of educational material to
enhance the skills of oral and maxillofacial surgeons in the detection and proper
diagnosis of oral cancer; the development of educational materials for general den-
tists, dental hygienists, and primary medical providers to heighten the detection of
oral cancer at an early stage; and the promotion of oral cancer screening, especially
among high-risk populations. The Board also accepted the recommendation that the
Oral Cancer Task Force be constituted as a special committee of the AAOMS to
develop a plan with strategic implementation to improve the outcomes of patients
with oral cancer. Further, the Board approved the recommendation to develop strat-
egies on an oncology subsection for future AAOMS Research Summits in conjunc-
tion with the Advisory Committee on Research Planning and Technology
Assessment. Finally, the Board approved the recommendation that the AAOMS
provide support for the International Academy of Oral Oncology by encouraging
AAOMS members and fellows to attend International Academy of Oral Oncology
meetings, present educational programs, and submit manuscripts to their journal,
Oral Oncology.
In 2012, Clark et al. (2012) conducted and distributed a survey to determine the
prevalence and trends of the US oral and maxillofacial surgery residency programs
in the arena of oral/head and neck oncologic surgery. Eighteen close-ended ques-
tions and one open-ended question comprised the survey that was distributed to 101
Head and Neck Tumor Surgery 273

accredited oral and maxillofacial surgery residency programs. The questionnaire

was grouped into the incidence of head and neck oncologic surgery-trained faculty
and recruitment-related questions, caseload related questions, program-specific
related questions, and academic productivity-related questions. Sixty-three of the
101 surveys (62.3%) were completed and returned. Ten program directors or chairs
were noted to be fellowship trained in head and neck oncologic surgery. Programs
with a fellowship-trained program director or chair were more likely to have another
fellowship-trained faculty member and performed more malignant tumor resec-
tions, neck dissections, and microvascular free flap reconstructions than residency
programs without program directors or chairs trained in head and neck oncologic
surgery. Programs that regularly engaged in tumor board discussions performed
more malignant tumor resections and neck dissections than programs that did not
regularly attend their institution’s tumor board meetings. Programs that presented
oncologic surgery-related research at national meetings performed more malignant
tumor resections and neck dissections than programs that did not present such
research at national meetings. Programs that presented oncologic surgery research
at national meetings were more likely to realize their residents entering fellowship
training in this discipline than programs that did not present oncologic surgery
research at these meetings. Finally, there was no difference in the prevalence of head
and neck oncologic surgery-trained program directors and chairs between 6-year
integrated and 4-year programs, and there was no difference in the number of malig-
nant tumor resections or number of neck dissections performed between the 6-year
integrated and 4-year programs studied in this report.
In 2016, the AAOMS Special Committee on Maxillofacial Oncology and
Reconstructive Surgery published their survey results related to fellowship program
graduates in our subspecialty (Kademani et al. 2016). The survey was sent to 64 oral
and maxillofacial surgeons who completed their fellowship from 2000 to 2014.
Thirty-four (53%) graduates responded, eight of whom completed the University of
Maryland program; five trained each at Legacy Emanuel Hospital and the University
of Tennessee; four trained at the University of Michigan; three trained each at the
University of Florida, the University of California-San Francisco, Louisiana State
University-Shreveport, and the University of Miami; and one trained at North
Memorial Hospital. When asked how many patients they treated each year, nine
respondents indicated greater than 100 and greater than 50% of the respondents
indicated that they treated greater than 50 patients per year. Eighty-two percent of
graduates were in academic positions, training fellows, and/or residents.
In 2019, the AAOMS established the standing Committee on Oral, Head and
Neck Oncologic and Reconstructive Surgery (COHNORS), thereby replacing the
MORS special committee. Of importance to the AAOMS was two issues including
the conversion from a special committee to a standing committee in recognition of
the importance of the committee’s work to the specialty and subspecialty. In addi-
tion, the name change occurred to better align with its purpose and duties while also
being consistent with the title of CODA-accredited fellowships and the American
Board of Oral and Maxillofacial Surgery (ABOMS) Certificate of Added
274 A. Deek and E. R. Carlson

Qualification (CAQ) examination, a discussion of which follows. The AAOMS

Board approved the name change in March 2019 through a bylaw change in the
AAOMS House of Delegates. In 2020, this committee is represented by board liai-
son, Dr. Mark Egbert; committee chair, Dr. Deepak Kademani; and committee
members, Dr. Eric Carlson, Dr. Brent Ward, Dr. Mohammed Qaisi, Dr. Steve
Schimmele, and Dr. Brian Woo. Dr. Paul Lambert serves as a consultant to the
COHNORS, and AAOMS staff liaisons include Mary Allaire-Schnitzer and Jennifer
Scofield.

12  ertification by the American Board of Oral

C
and Maxillofacial Surgery

The American Board of Oral and Maxillofacial Surgery is approved and recognized
by the Council on Dental Education of the American Dental Association and exists
as the certifying board for the specialty of oral and maxillofacial surgery in the
United States. In 1945, a committee congregated at the annual meeting of the
American Society of Oral Surgeons to establish the American Board of Oral Surgery.
In 1946, the American Board of Oral Surgery was incorporated under the laws of
the State of Illinois. The Board was approved by the Council on Dental Education
of the American Dental Association in 1947 with authorization to initiate the certi-
fication of specialists in our specialty. The Board was renamed the American Board
of Oral and Maxillofacial Surgery in 1978 to reflect the scope of the specialty. The
essence of the American Board of Oral and Maxillofacial Surgery is currently over-
seen by an eight-member Board of Directors including four directors, the secretary-­
treasurer, the vice-president, the president, and the past-president. Each member of
the Board of Directors is board certified by the American Board of Oral and
Maxillofacial Surgery and is a fellow of the American Association of Oral and
Maxillofacial Surgeons. A new director is elected each year to an 8-year term by the
House of Delegates of the American Association of Oral and Maxillofacial Surgeons.
The Board of Directors appoint an examination committee that serves the purpose
of administering the annual certification examination process.
Certifying boards in health-related professions exist to establish minimum stan-
dards of competency related to knowledge, experience, and training that result in
the ability to effectively and safely provide care to patients (Hupp 2015). Board
certification in medicine and dentistry was originally developed around recognized
specialties that arose from clinical specialty training beyond medical and dental
education. The certifying boards are designed to develop an examination process
that reflects residency training within a specific discipline. In so doing, specialty
education must be standardized for those future candidates of the board certification
process. As this educational standardization is not always possible, board certifica-
tion candidates will often participate in board review courses, and program directors
will typically look for ways that their residents will receive clinical and didactic
Head and Neck Tumor Surgery 275

education in areas tested by the certifying board. In the final analysis, the awareness
of a doctor’s board certification status is beneficial to patients requiring healthcare
services, hospitals, liability insurance companies, and third-party payers. The
advent of subspecialty education in medicine and dentistry has been driven by the
increasing complexity of patient diagnoses, as well as that of healthcare services,
the burgeoning of biomedical technology, and the need to limit the length of resi-
dency education (Dodson et al. 2004).

13  ertificate of Added Qualification in Head and Neck

C
Oncologic and Reconstructive Surgery

In 2014, the American Board of Oral and Maxillofacial Surgery initiated the process
of establishing a certificate of added qualification (CAQ) in head and neck onco-
logic and reconstructive surgery. The CAQ is designed for oral and maxillofacial
surgeons certified by the ABOMS who have established bona fide qualifications and
experience in this subspecialty and who conduct a clinical practice committed to
and focused on this subspecialty within oral and maxillofacial surgery. Possessing
the CAQ does not endow special privileges related to the practice of head and neck
oncologic and reconstructive surgery, does not bestow upon the certificate holder
comprehensive qualification for surgical privileges, and does not imply the exclu-
sion of other practitioners of either oral and maxillofacial surgery or other disci-
plines who do not hold this certification. Rather, the certificate of added qualification
has been developed to inform the public and healthcare professionals that the oral
and maxillofacial surgeon who possesses the certificate has completed subspecialty
education, has completed a certification examination process, and is qualified to
practice this subspecialty of oral and maxillofacial surgery. To be inclusive, the
CAQ observes primary eligibility pathway criteria and alternate eligibility pathway
criteria. Both pathways require that the candidate must hold full, active, unrestricted
hospital staff privileges to provide head and neck oncologic and reconstructive sur-
gery services, must submit a surgical case log, must be a diplomate in good standing
of the American Board of Oral and Maxillofacial Surgery, and must successfully
complete the CAQ 100-question examination. The results of the first three CAQ
examinations is noted in Table 3. This examination will continue to be administered
biennially going forward.

Table 3 Results of the certificate of added qualification examination in oral/head and neck
oncologic and reconstructive surgery of the American Board of Oral and Maxillofacial Surgery
Year of Number of candidates (primary pathway/alternate Number of passing
CAQ pathway) candidates
2016 17 (13 primary/4 alternate) 16
2018 5 (5 primary) 5
2020 9 (6 primary/3 alternate) 8
276 A. Deek and E. R. Carlson

14  ection of Surgical Oncology and Reconstruction

S
of the Journal of Oral and Maxillofacial Surgery

In 2011, newly appointed Journal of Oral and Maxillofacial Surgery editor-in-chief

Dr. Jim Hupp reformatted the structure of the journal into multiple discipline-­
specific sections. One section is devoted to surgical oncology and reconstruction,
exemplifying the prominence of our subspecialty of oral/head and neck oncologic
and reconstructive surgery. In 2016, 1691 papers were submitted to the Journal of
Oral and Maxillofacial Surgery including 247 papers being submitted to the surgical
oncology and reconstruction section of the journal. A disposition for 198 of these
papers was completed during 2017 including 120 papers devoted to surgical oncol-
ogy and 78 papers devoted to reconstruction. The diversity of these publications is
representative of the clinical scope of practice of our fellowship training programs
and that of the individuals practicing our subspecialty in oral and maxillofacial sur-
gery. The organization of the scholarly activity of our professional colleagues in
surgical oncology and reconstruction in this section of the Journal of Oral and
Maxillofacial Surgery provides formal consolidation of this scholarly effort.

15 The Provision of Microsurgical Reconstructive Surgery

Oral and maxillofacial surgery training has historically emphasized functional bone
graft reconstructive surgery for patients with post-ablative and post-traumatic
defects of the jaws. This commitment to this clinical service persists in the twenty-­
first century. In fact, oral and maxillofacial surgeons have emphatically recognized
that reconstruction does not merely refer to an exercise where a hole is filled with
tissue (Assael 2009b). Rather, our appreciation for orofacial form and function has
translated to truly functional reconstructions of the head and neck region. With the
introduction of predictable forms of soft and hard tissue free microvascular recon-
struction of the head and neck, as well as an increased number of microvascular
surgery trained members in our subspecialty, microvascular reconstructive surgery
has become a common element of the armamentarium of oral/head and neck onco-
logic and reconstructive surgeons in oral and maxillofacial surgery. In addition to
the well-accepted clinical advantages of immediate microvascular head and neck
reconstruction, overall success rates exceeding 95% justify the application of these
techniques to patients with oral/head and neck cancer (Fatahi and Fernandes 2013).

16 Future Opportunities and Directions

The development of the subspecialty of oral/head and neck oncologic and recon-
structive surgery is now steeped in tradition with effective branding in oral and
maxillofacial surgery. Our subspecialty is supported by excellence in clinical
Head and Neck Tumor Surgery 277

training, accreditation, certification, and overarching recognition by our parent sur-

gical association. Our international prominence is well recognized and relevant. Our
future, therefore, is unquestionably promising. While our primary challenge and
opportunity for growth might seem to merely maintain what we have created and
currently enjoy, improvement of the education of our trainees seems to be fertile
ground. Engagement in the educational process by fellowship program directors,
faculty, and fellows will enhance the ability for growth within our subspecialty. The
millennial trainees, clearly gifted in terms of their ability to learn, nonetheless rep-
resent a challenge for seasoned faculty in our subspecialty to effectively engage in
the educational process. It has been said that millennials will work to live, not live
to work, as is the case with the baby boomer generation (Assael 2006). In addition,
the existence of substantial educational debt might interfere with additional educa-
tion following the completion of residency training. This notwithstanding, the mil-
lennials are particularly able to succeed (Assael 2005). They believe that integrity
and honesty are the most important personality traits. As such, fellowship educators
must seize the moment to properly and effectively educate this new generation of
trainees.
Objective improvement in educational leadership (Carlson 2019; Carlson and
McGowan 2019; Carlson and Tannyhill 2019a; Carlson and Tannyhill 2019b;
Carlson and Tannyhill 2019c; Carlson and Tannyhill 2020) and outcomes by fellow-
ship faculty and the introduction of innovation and emerging technologies by fel-
lowship program directors and faculty will undoubtedly boost the fellowship
educational process. Such enhancement will improve the graduates of our fellow-
ship programs, likely rendering improved patient outcomes and safety. In addition,
the diversity and increased availability of clinical trials and personalized medicine
for thought-provoking and recurrent cancer cases will be value-added to patient
care. Finally, the reassessment and broadening of the educational process with
research opportunities in immuno-oncology and immunotherapy (Sim et al. 2019)
is likely to pay great dividends in the realization of future growth and increased
international prominence of our subspecialty of oral/head and neck oncologic and
reconstructive surgery.

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Surgical Flaps

Steven Halepas and Scott H. Troob

1 Introduction

Several factors have driven the evolution of tissue reconstruction, most significantly
trauma from war, knowledge of anatomy, and technological advancements. Before
discussing the history of tissue transfer, it is important to define terms to better
understand how the field developed. Flaps are classified by blood supply, location,
tissue content, and method of transfer. The flaps can be either random, axial, pedi-
cled, or free. Random flaps are supplied by the dermal and subdermal plexus. Axial
pattern flaps are supplied by a dominant vessel that is oriented along the axis of the
flap. Pedicle flaps are tissues supplied by a named artery. Free tissues are harvested
from a remote anatomic region, and the vascular connection is recreated at the
defect site.
Tissue reconstruction can also be classified according to the relationship between
the donor and recipient sites. Local flaps use adjacent tissues, regional flaps are
located near the defect but not immediately adjacent, and distant flaps are harvested
from different parts of the body. Flaps in the chapter will also be described based on
the tissue contents. As examples, cutaneous contain skin, myocutaneous contain
skin and muscle, fasciocutaneous contain skin and fascia, and osteocutaneous con-
tain skin and bone. Finally, the method of tissue transfer is used in naming the type
of flap. The methods of transfer include advancements, rotation, transposition, and
interpolated. Advancement flaps are mobilized along a linear axis toward the defect.

S. Halepas
Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University
Irving Medical Center, New York, NY, USA
S. H. Troob (*)
Department of Otolaryngology-Head & Neck Surgery, NewYork-Presbyterian/Columbia
University Irving Medical Center, New York, NY, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 281

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_16
282 S. Halepas and S. H. Troob

Rotational flaps pivot around a point at the base. Transpositional flaps are when
donor tissue is incised and lifted over an incomplete bridge of skin and placed into
the defect, an example of which is a rhomboid flap. Interpolated flaps are mobilized
either over or beneath a complete bridge of intact skin via a pedicle. The progression
of this discipline has occurred from random local tissue advancements, followed by
axial/pedicle regional rotational flaps, and ultimately to distant free flaps.
There are many instances that require reconstruction of defects in the head and
neck region, with the most common being secondary to trauma and cancer resec-
tion. When deciding which option to use, one should progress from simple to com-
plex options. Small defects can be closed primarily, moderately sized defects may
require grafts or local flaps, and large or complex defects require regional or distant
pedicled/microvascular free flaps. Reconstruction of the face is complex. The face
is composed of esthetic subunits. Each of these subunits is composed of different
tissue types that support vital functions such as mastication and vision. Different
areas of reconstruction require different elements which is why no one flap tech-
nique is perfect for all scenarios and many techniques have evolved over time.

2 Random Tissue Advancements

Historically, punishment for adultery and theft was nose amputation in ancient
Indian, Greek, and Roman societies. One of the first examples of reconstructive
surgery dates to ancient India during the sixth–fourth century BCE when nose
amputations were commonly practiced as a penalty for crimes. Nasal reconstruction
was born to repair this damaging practice (Greco et al. 2010). Historians credit
Sushruta of India with describing a regional pedicled flap for the nose in Samahita
ca. 1000–800 BCE. In modern day, the paramedian flap is used for other nasal
defects including those following cancer resections, burns, and trauma.
Many of the surgical techniques in the modern era have relied on the anatomical
discoveries dating back to the ancient Greeks and Romans (for more on anatomical
discoveries, see Chapter “Anatomists: The Basis of Surgery”). Celsus (25 CE) and
Oribasius (325–403 CE) described pedicled flaps and local tissue rearrangement for
the lips, nose, and ears (Fang and Chung 2014). As an example, Aulus Cornelius
Celsus in 30 CE described paired quadrilateral advancement flaps for upper lip
reconstruction. He stated “the method of treatment is as follows: the mutilation is
enclosed in a square, from the inner angles of this, incisions are made across, so that
the part on one side of the quadrilateral is completely separated from that on the
opposite side. Then the two flaps, which we have freed, are brought together
(Wallace 1978).” The fall of the Roman Empire resulted in the European Dark Age
and few recorded advancements in reconstruction occurred.
Marie Antoinette, the Queen of France in 1774, once said “There is nothing new
except what has been forgotten.” This concept will be a repeated theme throughout
the discussion of many flap techniques. Specific flap designs have fallen out of favor
over the years, only to regain popularity at later dates. Such an example comes from
Surgical Flaps 283

the fifteenth century, where European barber-surgeons “rediscovered” the flap tech-
niques of ancient India. The barber-surgeons were the primary surgical providers
from the eleventh to the seventeenth centuries in Europe. The guild of barbers had
no formal medical education until beginning of the sixteenth century. The first secu-
lar European medical school was established in Italy at Salerno. Subsequent medi-
cal schools were then established at Montpelier, Bologna, Paris, Oxford, and
Cambridge (Bagwell 2005) (for more on the barber surgeon era, see Chapter “The
Barber-­Surgeons”). The University of Bologna, in particular, always considered
surgery an integral part of medicine, and the University of Bologna will play a key
role in the evolution of tissue reconstruction.
It is not well known how the European surgeons of this era learned the tech-
niques of ancient India. At this time, southern Italy was the center of Latin, Greek,
and Arabic learning. Some believe that the Indian teaching of reconstructive surgery
was found in the collections of the Roman Empire. Since Italy was the hub for this
ancient collection, it is logical that Italian surgeons had the means to learn and uti-
lize these techniques. Gustavo Branca was a surgeon in Sicily, born in the early
1400s. He is often considered the inventor of “the Italian method” of nasal recon-
struction using skin from other parts of the body (see Fig. 1)1. There is no historical
evidence telling us whether there were surgeons before Gustavo in the Branca fam-
ily or why he was interested in nose reconstruction. It is also unclear how Gustavo
learned the information of Sushruta. Regardless, Gustavo Branca began using the
regional forehead flap technique of Sushruta for nose reconstruction. He later used
a skin flap from the cheek for reconstruction. Antonio Branca, Gustavo’s son, fur-
ther developed his father’s work using tissue from the arm for nasal reconstruction.
This is believed to be the first documented use of the upper extremity as a donor site
(Tomba et al. 2014). It is unclear whether the Branca family is the true inventor of
“the Italian method.” The Brancas had no successors and only worked in Sicily,
never leaving the island. It is unclear if their work was ever picked up by others or
“re-invented” independently. A historian in the 1400s, Bartholommeo Fazio, wrote:
“Branca, the elder, was the inventor of an admirable and almost incredible thing. He
conceived how he might repair and replace noses that had been mutilated and cut
off, and developed his idea into a marvelous art. […] For he conceived how muti-
lated lips and ears might be restored, as well as noses. Moreover, whereas his father
had taken the flesh for repair from the mutilated man’s face, Antonius took it from
the muscles of his arm, so that no distortion of the face should be caused
(Wallace 1978).”
Another prominent Italian family was involved in nose reconstruction during this
period. Vincenzo Vianeo was the first surgeon in his family, living in Calabria, Italy.
He was born in the early 1400s and had a nephew, Bernardino Vianeo, who was

1
Image from Wikimedia commons. Public domain image. Reproduced without alterations. https://
commons.wikimedia.org/wiki/File:Indian_method_of_surgical_restoration_of_the_nose._
Wellcome_L0017597.jpg Copyrighted work available under Creative Commons Attribution only
license CC BY 4.0 http://creativecommons.org/licenses/by/4.0/ http://catalogue.wellcomelibrary.
org/record=b1353614
284 S. Halepas and S. H. Troob

Fig. 1 The Indian method

of rhinoplasty. Indian
method of the restoration
of the nose by plastic
surgery, from article by BL
to Mr. Urban concerning
Cowasjee, a man who had
his nose reconstructed with
the aid of plastic surgery

born in 1464. Historians do not believe Vianeo had ever met the Branca family or
heard of their work. There is also controversy as to which was born first. Although
again it is unclear as to how Vincenzo learned his nasal reconstruction techniques,
it is documented that he directly taught his nephew Bernardino (Greco et al. 2010).
Some hypothesize that his techniques of arm-flap nasal reconstruction were influ-
enced by religious documents from India kept in the archives of Basilian monaster-
ies (Greco et al. 2010). The Vianeo family’s nasal reconstruction was similar to the
Branca family, using skin from the upper extremity. Bernardino would go on to
educate his sons Pietro and Paolo of the surgical technique. Pietro and Paolo became
well known throughout Italy for their surgical work. In 1561, a famous professor of
philosophy at the University of Naples came to Tropea to have the surgical brothers
restore his nose lost in an armed assault (Greco et al. 2010). It is said that the Viaeno
family was secretive in its surgical technique. Leonardo Fioravanti, a surgeon in
Bologna, wanted to learn Pietro and Paolo’s surgeries. Legend says that he tricked
Surgical Flaps 285

Fig. 2 Portrait of Tagliacozzi young. Circa 1580 (Ménard 2019) (left). Original illustration of the
Italian method (right)

the Vianeo brothers into assisting in some operations. Years later he would describe
the surgical technique in his work Il Tesoro della Vita Humana (Celani 2020; Greco
et al. 2010; Santoni-Rugiu and Mazzola 1997).
Gaspare Tagliacozzi, was born in 1545 in Bologna, Italy. Tagliacozzi likely knew
the methods of the Viaeno family from reading Leonardo Fioravanti’s work as
Tagliacozzi was a medical student while Fioravanti was a professor at College of
Physicians at Bologna University. Tagliacozzi became a professor of surgery and
anatomy at the Archiginnasio of Bologna. Among other contributions, he spent
years improving and developing the “Italian method” for nasal reconstruction. He
published a book entitled De Curtorum Chirurgia per Insitionem in 1597 (On the
Surgery of Mutilation by Grafting), where he described in great detail the technique
and the original works of the Branca and Vianeo families, without mentioning their
names (Santoni-Rugiu and Mazzola 1997). Tagliacozzi described nasal reconstruc-
tion using a flap of tissue from the upper arm (Ménard 2019). Soft tissue was taken
from the skin and deep to the upper biceps fascia and rotated to the nasal defect.
After healing of about 3 weeks the flap was divided (see Fig. 2).2 The true founder

2
This is a media file that Houghton Library believes to be in the public domain of the United States.
This applies to a work published before January 1, 1923 or the unpublished work of an author who
died more than 70 years ago. Houghton Library and Harvard University claim no rights in this
photographic reproduction of the work, and the image is free to download and reproduce for any
use, commercial or non-commercial, without any further permission required (Typ 525.97.820,
Houghton Library, Harvard University).
286 S. Halepas and S. H. Troob

of the “Italian method” is uncertain. The Vianeo and Branca family likely developed
the technique independently, but it is more likely that the Vianeo family influenced
Tagliacozzi work and publication.
One of the reasons that surgical technique in general took to develop and evolve
prior to this period was due to the limitation in disseminating information. This is
likely one of the reasons why two families in Italy were developing the same nasal
reconstruction technique with no knowledge of each other. With the invention and
proliferation of the printing press in the late fifteenth century, information began
spreading rapidly across Europe. Fioravanti’s work, Il Tesoro della Vita Humana,
for example, was translated into French, German, and English and spread across
Europe (Santoni-Rugiu and Mazzola 1997). With higher output printing, medical
journals would arrive in the 1660s, increasing the efficiency of knowledge sharing
(Fang and Chung 2014). In Europe, the mechanical movable printing press intro-
duced the era of mass communication in the sixteenth and seventeenth centuries,
and surgeons in Europe began to share information like never before. This allowed
major strides in medicine, surgery, and anatomy. Most notably was an English phy-
sician named William Harvey, who made significant contributions in the under-
standing of anatomy and physiology. In addition to describing in detail the systemic
circulation of the body, in 1682, he described the concept of arterial inflow and
venous outflow in the extremities with his tourniquet experiment on the forearm and
hand. This new understanding of vasculature would become instrumental in the
development of flap reconstruction (Haddad and Khairallah 1936; Harvey 1928).

3 Local and Regional Flaps

European surgeons would continue to repair defects by taking skin from local areas
until the fundamental understanding of the vascular system was developed. In 1743,
in an attempt to reconstruct a lid defect in a 14-year-old boy, Henri Francois Le
Dran described a sliding flap from the nose (Wallace 1978). In 1719, Renaulme de
la Garanne placed an arm flap (from the Italian method) into a fresh surgical defect
in the nose (Wallace 1978). Frank Hastings Hamilton, a surgeon in the 1840s, modi-
fied this and performed his cross-leg flap in treating a 15-year-old boy with chronic
ulcers. In 1862, Wood reported on the first distant flap coverage for upper extremity
defects with an axial groin flap in reconstructing a burn on the upper extremity of an
8-year-old girl (Wood 1863). Woods made direct reference to the Tagliacotian prin-
cipal in his work. Francois Chopart of France (1743–1795) performed advancement
flaps for lip reconstruction.
In 1855, a man named Iginio Tansini was born in Italy. He earned his medical
degree from the University of Pavia in 1878. Following this, he stayed on staff at the
Surgical Clinics and learned from Enrico Bottini before becoming professor of the
Surgical Clinics at Modena in 1888 (Maxwell 1980). Tasini had many accomplish-
ments as a surgeon. He was the first Italian surgeon to successfully perform a
­pylorogastric resection for cancer. He was also the first person to cauterize the
Surgical Flaps 287

stump of the trigeminal nerve following its transection in the treatment of trigeminal
neuralgia (Maxwell 1980). Most notably for this work, he is credited with the first
musculocutaneous flap. In 1896, he described a latissimus dorsi flap in the setting of
breast cancer (Tansini. 1896) (see Fig. 3). When performing mastectomies, Tansini
advocated for the excision of the skin to reduce the risk of recurrence of cancer after
the mastectomy. In order to reconstruct this defect, he described the latissimus dorsi
flap and highlighted the importance of vascularization for flap viability. Tansini con-
sistently experienced necrosis of the distal one-third of his original flap. After fur-
ther anatomical investigation with Professor Sala, an eminent anatomist from Pavia,
he noted that the latissimus dorsi muscles needed to be included with the scapular
circumflex. It is known now that he was mistaken only in his thinking that the scapu-
lar circumflex artery was more important than the subscapular and thoracodorsal
arteries in this flap (Maxwell 1980). “We can only speculate why this popular and
reliable procedure fell from favor, necessitating ‘rediscovery’ of musculocutaneous
flaps and revival of the latissimus dorsi flap (Maxwell 1980).” Tansini’s mastectomy
was eventually replaced by that of Halsted’s, and for reasons unknown his work

Fig. 3 Original photo of

Tansini’s latissimus dorsi
flap reconstruction. Tansini
method for the cure of
cancer of the breast.
Purpura, Francesco. The
Lancet.
171(4409):634–637.
(Figure 6 Reproduced with
permission and without
alteration)
288 S. Halepas and S. H. Troob

with the latissimus dorsi flap failed to carry forward. “Halsted’s mastectomy became
accepted as the standard mode of management for this disease…Thus, widespread
acceptance of Halsted’s procedure put that of Tansini’s to rest (Maxwell 1980).”
While substantial work took place in Italy, beginning in the nineteenth century,
Italy began to be overshadowed by Germany in regard to medicine and surgery,
especially because of their adoption of aseptic technique. Dr. Giuseppe Ruggi of
Bologna said “Italy is the most indifferent of all nations, and seems as if she is nei-
ther interested herself nor wished to interest herself in this method of treatment
[aseptic technique] which has been estimated so highly by the great surgical leaders
of Germany (Maxwell 1980).” Much of the soft tissue work in the late 1800s was
performed by German surgeons and ophthalmologists. In 1829, Fricke of Hamburg
described many alternative facial flaps using the temple for upper eyelid repairs and
tissue from the cheek for lower eyelid repairs (Wallace 1978). Jacques Lisfranc and
Napoleon’s surgeon Jean Dominique Larrey used the ancient technique of Celsus
for upper lip reconstruction with wide undermining that has been recommended by
Pierre Franco in 1561 (Wallace 1978). This would become known as the French
method. Karl Heinrich August von Burow was a German surgeon and ophthalmolo-
gist born in 1830. He improved on the French method for lip repair when he devel-
oped a technique in which a triangle of skin and subcutaneous fat is excised so
tissue can be advanced without buckling, referred as a “Burow’s triangle.” Burrow’s
triangle is utilized today, especially as an effective means for correcting “dog ears.”
Advancements in understanding of soft tissue handling are vital for the future use of
surgical flaps.
The nineteenth century would lead to substantial breakthroughs in medicine by
people like Louis Pasteur, the father of microbiology (1822–1895), and Joseph
Lister (1827–1912), the father of modern surgery. Prior to the industrial revolution,
most soft tissue injuries occurred due to warfare. Gunshot injuries became an
increasing portion of battle wounds. During the American Civil War (1861–1865),
70% of traumatic injuries involved the limbs, just 3% underwent debridement with
amputation as the preferred method of treatment (Fang and Chung 2014). With
knowledge from Louis Pasteur and Joseph Lister, soldiers were less likely to die
from infection after these injuries, thereby increasing the number of survivors with
soft tissue defects. As an example of how gunshots provided the means for advanc-
ing flap reconstruction, in 1868, Carl Thiersch in Germany used a superiorly based
nasolabial flap to close a palatal fistula resulting from a gunshot wound (Wallace
1978). The search for reconstruction options for facial defects would continue, with
an emphasis on pedicles. Although he is best known for his discovery of paraffin
and Vaseline, Robert Gersuny in Austria performed the first island flap reconstruc-
tion in 1887 (Wallace 1978). He used a random island of neck skin on a pedicle of
subcutaneous tissue to provide lining for a defect in the mouth. More than a decade
later, George Howard Monks in Boston would then use an axial island flap of fore-
head skin to reconstruct a lower eyelid (Wallace 1978).
Sir Harold Gillies was a New Zealand-born otolaryngologist, born in 1882, who
is often considered the father of modern plastic surgery. He had many contributions,
most notably in the field of craniofacial surgery and tissue repairs. During World
Surgical Flaps 289

War I (1914–1918), he was working in the Royal Army Medical Corps as the medi-
cal director to a French-American dentist named Valadier. Auguste Charles Valadier
attended the College of Physicians and Surgeons at Columbia University, graduat-
ing in 1895 followed by a dental degree from the Philadelphia Dental College (now
the school of Dentistry at Temple University). When war broke out in August of
1914, he volunteered his services to the British Red Cross Society. The British
Army would not have a separate commissioned dental corps until 1921. Gillies said
“The credit for establishing the first plastic and jaw unit, which so facilitated the
later progress of plastic surgery, must go to the remarkable linguistic talents of the
smooth and genial Sir Charles Valadier (Cruse 1987).” Valadier worked on jaw
repair and was using novel skin graft techniques. This interested Gillies who left his
post with Valadier for Paris to work with Hippolyte Morestin.
Hippolyte Morestin was a French surgeon, known as the Father of Mouths.
“Gillies described his meeting with Morestin thus: “In the space of a single moment
he could reveal the gentleness of a kitten and the savagery of a tiger. He received me
kindly, and I stood spellbound as he removed half of a face distorted with a horrible
cancer and then deftly turned a neck flap to restore not only the cheek but the side
of the nose and lip, in one shot. Although in the light of present-day knowledge it
seems unlikely that this repair would have been wholly successful, at that time it
was the most thrilling thing I had ever seen. I fell in love with the work on the spot
(Lalardrie 1972).” Gillies was fascinated with this work, and when he returned to
England, he started the facial injury ward at the Cambridge Military Hospital. As
demand grew, this unit became inadequate and the Queen’s Hospital, in Sidcup,
opened in 1917. When faced with a horrific facial burn, Gillies invented the tube
pedicle. He stated: “The process of thought on the problem led one to decide on a
double pedicled chest flap, the pedicles to be tubed to prevent their being infected or
exposed, to leave attached to these pedicles as large a chest flap as was deemed
viable and then to place this large flap onto the face, excising the area covered by it
[…] In regard to the raw area of the chest no attempt at closure was made and the
main line of treatment carried out for this area was the use of paraffin No.7. At one
stage hot fomentations were also applied to clean the surface. No grafting from the
patient was attempted but three small grafts from another case were laid on the
granulations, without success (Wallace 1978).” The waltzing tube pedicle, some-
times known as a walking-stalk skin flap, is a tubular pedicle connected from the
donor site to the target, allowing blood flow through the pedicle. The connection is
divided after the defected site heals (see Fig. 4).3 Gillies treated over 8700 facial
trauma patients at the Queens Hospital and the Park Prewett Hospital (Gebran and
Nam 2020). Gillies was unaware that just 1 year prior, in 1916, Vladimir Petrovich
Filatov, an ophthalmic surgeon in Odessa, would perform the first tube pedicle in a
human after raising a tube pedicle on a rabbit and noting that the hair regrew after
shaving, thereby assuming it had adequate blood supply (Wallace 1978). World War

3
Marck KW, Palyvoda R, Bamji A et al. The tubed pedicle flap centennial: its concept, origin, rise,
and fall. Eur J Plast Surg. 2017;40:473–78. https://doi.org/10.1007/s00238-017-1289-8 Image is
of springer collection, need permission
290 S. Halepas and S. H. Troob

Fig. 4 Four drawings illustrating the first tubed pedicle flap of Filatov in 1916

I would provide a plethora of surgical patients in which the foundations of plastic

reconstructive surgery would grow. (For more information on Gillies, see Chapters
“The Legacy of Maxillofacial Surgery During The Great War” and “Midface
Trauma”).

4 Deltopectoral and Pectoral Flap

In 1945, Vahram Bakamjian, graduated from medical school at the American

University of Beirut in Lebanon. He then came to the United States to attend an ear,
nose, and throat residency at Columbia University in 1956 (Serletti et al. 2012).
After residency, Dr. Bakamjian was recruited to Roswell Park Memorial Institute.
In 1965, he performed one of the first modern deltopectoral flaps (Krishnamurthy
2015). While the deltopectoral flap sometimes is called the Bakamjian flap, the
technique was first described by Aymard more than 40 years prior when he reported
on raising a medially based fasciocutaneous flap from the shoulder skin for a nasal
construction (Aymard 1917). Conley, another surgeon in New York, introduced the
modified laterally based deltopectoral flap supplied by the lateral thoracic and tho-
racoacromial branches in 1953 (Hwang 2016). The deltopectoral flap did not gain
much popularity until Bakamjian reported on his use with this technique. The del-
topectoral flap which is a rotational flap that Bakamjian demonstrated was more
dependable than a free skin graft. With this he developed the two-staged method for
pharyngoesophageal reconstruction.
In 1969, Hueston in Melbourne, Australia, advanced the work of Aymard and
Bakamjian, by including “the pectoralis major muscle in the chest skin flap and
named it a compound pectoral flap. He was the first to combine a skin flap with the
pectoralis major muscle, and used this technique to repair large defects of the chest
wall (Hueston and McConchie 1968; Hwang 2016).” Ariyan’s work in 1979 demon-
strated the flap could be raised as an axial myocutaneous flap on the thoracoacro-
mial artery. He described four cases, two were raised as a peninsular flap, one as an
island flap, and one as a double paddle island (Ariyan 1979). In that same year, Baek
described the anatomy, design, and blood supply of the pectoralis major
Surgical Flaps 291

myocutaneous island flap after dissecting 25 cadavers and performing the procedure
on 26 patients (Baek et al. 1979). It is believed that these two surgeons developed
the technique independently but simultaneously. This was a transition point in the
world of head and neck reconstruction because it provided a large amount of well-­
vascularized tissue to cover defects from the neck up. The pectoral flap had major
benefits over the deltopectoral flap with its rich vascularity, large skin area, increased
bulk, and ease of harvest. This allowed coverage of almost anywhere in the oral cav-
ity and became the workhorse of the 1980s and 1990s. Before the era of microsurgi-
cal free flaps, regional deltopectoral flaps and the pectoralis major myocutaneous
flaps were most often utilized in the head and neck.

5 The Foundations of Vascular Surgery

The foundations of vascular surgery, the building block for microvascular surgery,
begin with Alexis Carrel. Carrel was a French surgeon born in 1873. He attended the
University of Lyon for medical school. His interest in vasculature is said to have
initiated with the assassination of Sadi Carnot in 1894. Sadi Carnot was the presi-
dent of the French Republic and was stabbed in the abdomen while visiting Lyon.
At that time, it was believed that major vascular injuries were lethal, but Carrel felt
that they could be repaired (Dente and Feliciano 2005). In 1903, he cared for a
young woman dying of tuberculosis peritonitis. They took a trip to Lourdes where
she was cured. The women proclaimed this miracle and named him as her primary
witness. This was against Catholic teachings at this time and he was ridiculed by the
French community. Due to this, and failing exams for faculty positions, he was
unable to receive a hospital appointment in France requiring his immigration, first
to Canada and ultimately to the United States. He accepted a position in Chicago in
1904. At Chicago University he met Charles Guthrie and together they perfected
their vascular anastomotic technique. He pioneered new techniques like the triangu-
lation of vessels and the use of sharp, round-bodied needles to minimize damage
and irrigation with crystalloid solution. Carrel won the Nobel Prize in Physiology or
Medicine in 1912 in recognition of his “work on vascular suture and the transplanta-
tion of blood vessels and organs” (Alexis Carrel – Biographical 2021; Dente and
Feliciano 2005).
While Carrel and Guthrie’s work was monumental, development of the surgical
microscope was a truly pivotal moment in the history of microvascular surgery.
Otologists were the first physicians to use such microsurgical techniques and Carl-­
Olof Siggesson Nylen is regarded as one of the founders of microsurgery. In 1921,
he developed the first surgical microscope as a modification of the monocular
Brinell-Leitz microscope (Schultheiss and Denil 2002). In 1922, Gunnar Holmgren
created the binocular microscope. In the 1950s, Carl Zeiss further advanced
Holmgren’s binocular microscope seen in Fig. 5.4

4
Reproduced without modification with permission from Zeiss
292 S. Halepas and S. H. Troob

Fig. 5 OPMI1 was the

first surgical microscope
developed in cooperation
with leading surgeons,
Professor Hirst Wullstein
and Professor Heinrich
Harms. Source: Carl Zeiss
archives

The foundation of microvascular surgery, the anastomosis of vessels using

microscopic techniques, was first performed by Jules Jacobson in 1960 at the
University of Vermont to couple small vessels of 1.4 mm diameter in dogs and rab-
bits (Jacobson et al. 1962; Rickard and Hudson 2014). Harry Buncke was an
American plastic surgeon and often referred to as the “Father of Microsurgery” for
his contributions to the field. Ronald Malt performed the first successful replanta-
tion of a forearm in 1962, as a chief resident at Mass General Hospital (Malt and
McKhann 1964). In 1973, in the People’s Republic of China, in Shanghai Sixth
People’s Hospital, the first successful distal forearm replantation was performed by
Zhong-Wei Chen and coworkers. There is debate over who should receive credit for
replantation first. “Ronald Malt performed the reattachment surgery on a boy who
had an accident in 1962, but he published his case report two years later in 1964.
Chen Zhongwei performed a similar surgery on a worker who cut off his forearm in
1963, but he published his case report the same year (Fan 2020).” Regardless, credit
should be awarded to both surgical teams as it was truly a remarkable milestone.
Yoshio Najayama et al. completed the first free flap transfer of the intestine to the
head and neck region in 1964 (Fang and Chung 2014). Surgeons in China (Dong-Ye
Yang and Yu-Dong Gu), unknown to the rest of the world at that time, would then
perform the first extremity free flap of a human microvascular toe to thumb transfer
in 1965 (Chang 1979; Fang and Chung 2014; Yang et al. 1977). In 1966, Buncke
used microsurgery to transplant a primate’s great toe to its hand (Buncke et al. 1966).
At the same time, Donagy and Tasargil organized the first microvascular surgery
symposium, later published as Microvascular Surgery: Report of the First
Conference, October 6–7, 1966 (Link et al. 2010). They outlined basic approaches
to microvascular surgery: suture technique using silk, nylon, and metallic suture
material; use of adhesive substances; the use of micro-staples; and electrocoagula-
tion. As examples, they stated that a 1 mm vessel would require 10-micron flexible
sutures which in 1960 were being manufactured by DuPont. They fabricated many
different types of suture materials and experimented with different variations.
Surgical Flaps 293

“Microfine manipulators of various shapes were fashioned by etching down

stainless-­steel wires mounted in 25 and 30 gauge hypodermic needles. These were
used to handle the vessels atraumatically (Peardon Donaghy and Gazi Yașargil
1966).” The Mark V instrument was developed to staple vessels between 1 and
2 mm in diameter. At this time, research was conducted to see if adhesive material
could repair blood vessels or provide alternatives to conventional suture or staple
repair. They used adhesives such as Eastman 910, a methyl 2-cyanoacrylate mono-
mer, and M2C-2 a similar compound with methyl methacrylate.
John Cobbett was a plastic surgeon at Queen Victoria Hospital, East Grinstead,
and Lewisham Hospital. As part of a research program at East Grinstead, he became
interested in small vessel anastomosis. In 1968, Cobbett performed the first human
microsurgical transplantation of the great toe to the thumb in the English-speaking
world, 3 years after that of the Chinese (Cobbett 1969). He later went on to found
the British Society for Surgery of the Hand.
Three events in the 1970s are believed to be the foundations that enabled the
progression of flap surgery: the advancement of surgical equipment, the identifica-
tion of flaps as a reliable option for reconstruction, and better understanding of
anatomy. The development of microsurgical instruments by individuals like Acland
in 1969 launched microsurgery into a more common practice (Acland 1969). These
instruments included fine-tipped toothed forceps for minimal damage of delicate
vessels, microsurgical scissors, and vessel dilators (Corlett et al. 2015).
In 1970, Milton, a plastic surgeon, debunked a long-believed myth by demon-
strating that success of a flap was not dependent on the length to width ratio, but on
the blood supply that is incorporated into the flap. This fact was coupled a year later
with Strauch, Bloomberg, and Lewin at the Montefiore Hospital, who noted that
mandibular replacement following mandibulectomy is challenging. There is often a
limit of local tissue and rotational flaps often requiring multiple procedures based
on the blood supply. They hypothesized that a better approach would be to insert a
graft with its own blood supply. They reported on isolating a vascularized rib to the
internal mammary vessels and successfully transplanted this to reconstruct the jaw
in a dog (Strauch et al. 1971). Surgeons at this time realized the importance of the
blood supply and the ability to use the microscopic anastomoses discovered by
Jacobson and Buncke to use free flaps from distant donor sites, rather than just rota-
tional flaps, in reconstruction.
G. Ian Taylor and Ronald Daniel, two plastic surgeons in Melbourne, Australia,
identified a similar shortcoming to Strauch and his colleagues, specifically in recon-
struction after trauma to the lower extremities. When the skin is lost, early flap
coverage is often required, but local rotational flaps are often inadequate (see Fig. 6).
They performed the first successful free flap transfer in a human in 1973 (Taylor and
Daniel 1973). They used a large flap based on the superficial circumflex iliac vessel
and superficial inferior epigastric vessels described by McGregor and Jackson, to
repair the defect with microvascular anastomosis. They chose the 1.8 mm superfi-
cial inferior epigastric artery for anastomosis, and the superficial circumflex iliac
artery was ligated (Taylor and Daniel 1973).
294 S. Halepas and S. H. Troob

Fig. 6 The pyramid

represents the escalation
ladder for closing defects.
More advanced closures Free Tissue
are based on vasculature Transfer
and the principles
discovered by Buncke and
Regional Flap
others that a pedicled skin
flap is more dependable
Full thickness graft
than a free skin graft for
large reconstructions
Split thickness graft

Secondary intention

Free flap surgery could not have occurred without detailed understanding of the
vascular system of the human body. Across the world, for over a century, numerous
anatomists were involved in understanding this complex system (Taylor 2015).
Unfortunately, many of these studies went unnoticed by the English-speaking world.
The flap designs of the 1970s sent many surgeons back to anatomy labs to improve
on their understanding of the architecture for better flap success. JB McCraw per-
formed experimental studies in dogs using myocutaneous flaps based on the gracilis,
sartorius, biceps femoris, trapezius, and rectus abdominis muscles in 1977 as well as
in human cadavers (McCraw and Dibbell 1977). Taylor and colleagues performed
many dissections and injected lead oxide into the arterial tree of more than 1000
fresh cadavers and over 3000 individual muscle studies. As their anatomical studies
progressed, they moved from individual tissues such as skin to compound flaps sup-
plied by a single vascular pedicle such as skin and muscle or skin muscle and bone
(Taylor et al. 1979a; Taylor et al. 1983; Taylor and Ham 1976; Taylor and Townsend
1979). Their work reinforced the concept that a single vessel supplied multiple tis-
sues types in a specific region, an understanding that we take for granted today. They
further worked on investigating the venous system, and the lymphatics lead to the
concept of the “angiosomes.” “As a result of the total-body studies of the blood sup-
ply to the skin and underlying deep tissues, combined with reviews of previous
works, especially those by Manchot and Salmon, it has been possible to divide the
body into three-dimensional anatomical vascular territories. These three-dimen-
sional composite blocks of tissue, supplied by a source artery and its accompanying
vein that span between skin and bone, are defined as angiosomes (Taylor 2015).”

6 Radial Forearm Flap

The radial forearm flap was detailed by Yang et al. in 1981, for resurfacing the neck
secondary to burn contractures (Yang et al. 1997). The blood supply of the forearm
skin flap comes from the cutaneous branches of the radial, ulnar, posterior, and
anterior interosseous vessels and was successful in 59 out of 60 flaps in his report.
Surgical Flaps 295

The concept of this flap was first used in China in 1978, by Guo-fan, Baoqui, and
Yuzhi for neck resurfacing after a burn (Yang et al. 1997). In 1982, Song et al. pub-
lished in English their experience with this flap at the Beijing Plastic Surgery
Hospital, in the Clinics in Plastic Surgery. The western surgeons at that time referred
to it as “the Chinese flap (Song et al. 1982).”
Soutar provided the first English-language description of the use of the cutane-
ous and osteocutaneous forearm flap in the oral cavity reconstruction in 1983
(Soutar et al. 1983). This paper caused a paradigm shift. Prior to this, reconstruction
in the oral cavity was done with the bulky pectoralis flap. Soutar et al. noted their
radial forearm flap had several disadvantages as it is difficult to raise and produce a
donor defect that restricts immediate postoperative mobilization. In 1985, Fenton
and Roberts described a method to improve donor sites of the radial forearm (Fenton
and Roberts 1985). The authors suggested placing the wrist in flexion to expose the
tendon of the flexor carpi radialis. The skin edges of the defect can then be advanced
and sutured to the forearm muscles. Once this is complete, the central muscle fibers
of flexor pollicis longus can be sutured to the muscle belly of the flexor digitorum
superficialis, thereby covering the tendon of flexor carpi radialis noting a better
functional and cosmetic result. In 1986, Soutar et al. published on 60 flaps present-
ing uneventful primary healing with no fistula formation and return of oral function
(Soutar and McGregor 1986). The average hospital course was 17.8 days. They had
six microvascular failures. Most of the described patient morbidity was secondary
to radiotherapy of the underlying malignancy. Flap reconstruction of the head and
neck is often the result of malignancy, and the history of radiation oncology has
been a major component in the evolution of head and neck reconstruction (for more
on this, see Chapter “Radiation Oncology”).
The harvest technique was further developed by Lutz et al. in 1999 where they
described a suprafascial elevation of the radial forearm flap (Lutz et al. 1999). The
1990s saw a major change in the reconstruction of bony defects in the face. Large
mandibular defects were repaired with a fibular, iliac crest, or scapular and large
maxillary defects were mostly soft tissue via the rectus. In 2003, Villaret and Futran
reported on 34 patients that were reconstructed with radial forearm osteofaciocuta-
neous free flaps in the maxilla or mandible (Villaret and Futran 2003). The donor
site was rigidly fixated and a skin graft was placed at the site. The patients were
followed for 10–54 months. Seven patients had anterior maxillectomy defects and
27 patients had lateral mandibulectomy defects. They reported no flap failures or
donor site fractures. This was an important claim because at that point, 25% of pub-
lished cases reported a radial bone fracture.

7 Deep Circumflex Iliac Artery Free Flap (DCIA)

The iliac crest was one of the first of three major donor sites for widespread use in
reconstruction of the mandible. Early iliac crest harvesting was based on the use of
the superficial iliac vessels. In 1979, Taylor, Townsend, and Corlett recommended
296 S. Halepas and S. H. Troob

the use of the deep circumflex system as a superior alternative for this technique
(Taylor et al. 1979b). Their discovery was interestingly put:
During the dissection of the groin, the deep circumflex iliac vessels were encoun-
tered; because the bone graft was to be somewhat larger than usual, these vessels
were dissected out as well and the graft was finally isolated on both vascular sys-
tems. Profuse bleeding was seen from all tissues. However, when the superficial
system was temporarily occluded, there was copious arterial bleeding from the
entire bone, but sluggish perfusion of the overlying skin. When the clip was removed
and applied to the deep circumflex artery, the reverse situation occurred (Taylor
et al. 1979b).
This observation in the operating room resulted in 40 dissections of the deep
circumflex iliac vessel in cadavers and solidified the connection between the deep
circumflex iliac artery (DCIA) and the superficial circumflex iliac artery (SCIA).
Understanding the anatomical vascular supply allowed Taylor and colleagues to
discover this new technique, which formed the foundation for the discoveries of the
1970s and 1980s. The benefit of the use of the deep circumflex iliac artery was con-
firmed by Sanders and Mayou in 1979 when they used an iliac crest artery free flap
to reconstruct a compound fracture of the tibia and fibula in a 29-year-old man.
The following year, Franklin et al. reported the use of the DCIA free flap for
mandibular bone and soft tissue reconstruction (Franklin et al. 1980). They acknowl-
edged that no other flap to date so closely approximated both the mandibular thick-
ness and curvature. Problematically, this flap is bulky and often requires many
debulking procedures in the oral cavity. To remedy this, the internal oblique free
muscle flap based on the ascending branch of the DCIA became the soft tissue com-
ponent of the DCIA free flap. In 1989, Urken used the iliac crest bone flap with the
internal oblique muscle in mandibular reconstruction (Urken et al. 1989). In 1996,
Brown described the DCIA flap in which the internal oblique muscle was used for
maxillary reconstruction (Brown 1996; Brown et al. 2002).
The DCIA flap is highly favorable as it provides excellent contour and can
replace both the height and width of the native mandible. However, this flap is lim-
ited to about 16 cm which is not enough for complete mandibular reconstruction.
The average pedicle size is 5–7 cm which can sometimes limit reconstruction. In
addition, obesity is a relative contraindication as the bulky skin paddle becomes less
reliable.

8 Fibula Free Flap

The fibula free flap has gained widespread use as a mainstay of reconstruction in the
maxillofacial region. Building on the principals of microvascular design and free
flaps, in 1975 Taylor described the first fibula free flap transfer in humans in the
extremities (Taylor et al. 1975). It was not until 1989, however, when Hidalgo pub-
lished the use of osteocutaneous fibula free flaps for use in mandibular reconstruc-
tion (Hidalgo 1989). He described 12 patients who underwent mandibular
Surgical Flaps 297

reconstruction with an average mandibular defect of 13.5 cm. He used a lateral

approach to the dissection of the fibula in all patients, and most of the bone was
harvested regardless of the amount needed for reconstruction. The bone was oste-
otomized first and then the peroneal artery and vein were divided and ligated dis-
tally. The anatomical basis and vasculature have been heavily studied to support the
use of this technique. In 1986, Wei et al. described the reliability of the vasculature
(Wei et al. 1986). There are four to eight perforators along the fibula making the
vascularity of the bone highly dependable (Urken et al. 1998; Wei et al. 1994). A
decade later, Hidalgo reported on 82 patients who underwent reconstruction with
reliable outcomes (Hidalgo and Pusic 2002). The fibula became an attractive donor
site as it has ample bone length available for reconstruction and has relatively uni-
form consistency and cross-sectional size, and osteotomies can be performed to
shape to the intended position.
While numerous options exist for the reconstruction of the maxilla and mandi-
ble, the fibular free flap has become the workhorse because of its versatility and
numerous other factors. One of the added benefits is its favorable bone quality for
dental rehabilitation with dental implants (Patel et al. 2019). In 1993, Huryn et al.
reported on the osseointegration of implants in microvascular free fibular recon-
structed mandibles. In 2013, the first “Jaw in a day” surgery was performed by
Levine, Hirsch, and colleagues using digital technology, placing dental implants
into the fibular bone, allowing for immediate dental prosthetic rehabilitation (Levine
et al. 2013).

9 Scapular Free Flap

The scapular free flap was first described by dos Santos in 1980 and is one of the
most versatile flaps for the head and neck (Santos 1980). Bone, muscle, fat, fascia,
and skin can be transferred via this flap design. Gilbert and Teot illustrated success-
ful scapular free flaps in lower extremity reconstruction in 1982 (Gilbert and
Teot 1982).
In the same year, Nassif et al. described an anatomical study of 20 fresh cadavers
and found a constant artery descending along the lateral border of the scapula that
was not previously described, which they referred to as the cutaneous parascapular
artery (Nassif et al. 1982). The circumflex scapular artery is a branch of the sub-
scapular artery which originates from the axillary artery. After the circumflex scapu-
lar artery travels through the triangular space, it branches into the transverse
cutaneous scapular branch and a cutaneous parascapular branch. In 1987, Batchelor
and Bardsley described the use of a bi-scapular free flap in a leg and noted that the
whole flap was being adequately perfused by the single upper pedicle (Batchelor
and Bardsley 1987). Deraemaecker et al. in 1988 reported on the angular branch of
the thoracodorsal artery and vein as a potential additional blood supply for the cau-
dal portion of the lateral scapular border (Deraemaecker et al. 1988).
298 S. Halepas and S. H. Troob

In 1990, Sullivan et al. published their experience with five cutaneous scapular
flaps and 31 osteocutaneous flaps for head and neck reconstruction (Sullivan et al.
1990). One hundred percent of the cutaneous and 90% of the osteocutaneous flaps
were successful. One flap failed secondary to osteoradionecrosis and the second due
to arterial insufficiency, also likely secondary to radiation. The third failed flap was
caused by venous thrombosis. In 1991, Coleman and Sultan showed that the angular
artery allowed the harvesting of two separate bone segments (Coleman and Sultan
1991). These can be independently harvested on separate branches of the subscapu-
lar artery and vein which was revolutionary at the time, most notably for the ability
to harvest the scapular tip independently from the lateral border (Gibber et al. 2015).
In 1994, Moscoso et al. preformed a comparative anatomic study of bone and noted
that overall, 78% of harvested scapular bone segments were deemed for implant
placement with a height of 10 mm and a width of at least 5 mm which supports the
use of this flap design for dental rehabilitation after reconstruction (Moscoso
et al. 1994).
Starting in the early 2010, the scapular tip free flap gained renewed interest as a
modification of the scapular angle free flap. This flap design is often utilized in
maxillary reconstruction. If the circumflex artery is scarified, the pedicle can be up
to 20 cm long, much longer than alternative flaps (Ferrari et al. 2015).

10 Rectus Abdominis Free Flap (RAFF)

The rectus abdominis flap was described in 1977 by Mathes and Bostwick in the
setting of abdominal reconstruction after trauma using a rotated pedicle (Mathes
and Bostwick 1977). The rectus abdominis muscle flap was then described by
Pairolero and Arnold in 1980 to reconstruct chest wall defects following sternotomy
complications (Pairolero and Arnold 1984). In this case study, a total of 67 muscle
transpositions were performed, 63 of which were pectoralis, three rectus, and one
latissimus dorsi. The rectus abdominis was used as a rotational muscle flap. The
anatomical premise of this flap was nicely described by Taylor and Boyd, who illus-
trated the cutaneous perfusion of the abdominal skin based on the deep inferior
epigastric artery and vein through injections studies (Taylor et al. 1984). In 1985,
Drever et al. used a rectus abdominis myocutaneous flap for breast reconstruction
(Drever and Hodson-Walker 1985). When Drever first described this flap, he closed
the donor site with mesh, but work of other surgeons resulted in a transition to clos-
ing the donor site directly. In 1986, Sakai et al. described the extended vertical rec-
tus abdominis myocutaneous (VRAM) flap for breast reconstruction (Sakai et al.
1989). Prior to this the rectus abdominis myocutaneous flap was oriented as a lower
abdominal transverse rectus flap. The authors noted that the defect is in the axillary
region, and the lower abdominal transverse rectus abdominis myocutaneous flap
was not reliable, hence the need for this modification. Over a decade later, Pennington
and Pelly reported some of the first clinical applications of the free rectus abdominis
musculocutaneous flap with a transfer for a facial defect in 1978, based on the
Surgical Flaps 299

inferior epigastric vessels (Pennington and Pelly 1980). This technique has proved
advantageous as it has a reliable soft tissue donor and a long pedicle and can cover
large defects.
Koshima and Soeda used the skin territory of the rectus abdominis muscle to
reconstruct the floor of the mouth. This perforator vessel was followed toward the
deep inferior epigastric vessel and dissected from the rectus abdominis muscle and
resulted in a thin skin flap with an intact muscle left behind (Koshima and Soeda
1989). Allen, Treece, and Tucker worked to modify the rectus abdominis flap into
the deep inferior epigastric perforator (DIEP) flap which is a technique where skin
and tissue are taken from the abdomen to recreate a defect without the use of muscle
(Allen and Treece 1994; Allen and Tucker 1995). In 2010, Masia et al. reported on
100 patients over a 10-year period using DIEP flaps in head and neck reconstruction
(Masià et al. 2011). The overall flap survival rate was 97.1%. The DIEP flap is
advantageous in that it can provide bulk if the rectus muscle is raised with the flap
and it can allow easy molding if the cutaneous and muscular components are
separated.

11 Anterolateral Thigh Flap (ALT)

This flap was first described by Song et al. in 1984 at the Beijing Plastic Surgery
Hospital as a septocutaneous flap (Song et al. 1984). In 1979, Song found that
although the cutaneous arteries were not suitable for vascular anastomosis, they
could be traced to a more proximal vessel, and a free flap could be used off the
intermuscular septal vessels. They described three thigh flaps, the anterolateral, the
anteromedial, and the posterior. In 1990, Begue et al. described the vasculature of
the descending branch of the lateral circumflex artery of the thigh and the principle
behind this flap technique (Bégué et al. 1990). While the vasculature is not constant,
Koshima et al. noted the technique is safe because there are usually accessory
branches deriving from the lateral circumflex femoral vessels which can be included
(Koshima et al. 1989). In most cases the flap relies only on musculocutaneous per-
forators. Malhotra et al. performed a cadaveric study that determined the musculo-
cutaneous perforators to the ALT free flap entered the vastus lateralis muscle within
2 cm of the muscle border proving a good landmark when harvesting (Malhotra
et al. 2008).
In the early 2000s the flap gained popularity in North America because of its use
in extensive head and neck defects due to its bulk and low donor site morbidity. The
ALT flap is a good replacement for oral cavity, pharyngeal, and cutaneous defects
(Agostini and Agostini 2008). The ALT flap has also proved a good alternative to
the radial forearm flap (Valentini et al. 2008).
The 1990s and early 2000s were a period of heavy utilization and focus on the
recently developed vascular free flaps of the 1970s and 1980s, being used routinely
in head and neck reconstruction. Since their inception, critics of free tissue transfer
have detailed their downsides, namely, that they are long surgeries and resource
300 S. Halepas and S. H. Troob

intensive, can be associated with donor site morbidity. Partially as a response to

these criticisms, there recently has been renewed interest in low-morbidity, highly
versatile regional pedicled flaps. Examples of these were the supraclavicular, sub-
mental island, and facial artery musculomucosal flaps.

12 Supraclavicular Flap

In 1979, Lamberty et al. published an article describing 15 preserved cadaver and

22 fresh cadaver dissections in which they identify the thyro-cervical trunk and the
associated vasculature of the transverse cervical artery and supraclavicular artery.
The authors then used this information with two clinical patients in which they
raised two axial flaps depending on the supraclavicular artery (Lamberty 1979).
This flap was not heavily utilized until it was reintroduced in 1997, when Pallua
et al. described the supraclavicular artery island (SAI) flap for reconstruction of
cervicomental scars (Pallua et al. 1997).
During the following decade, supraclavicular flaps increased in popularity
because of the good color and texture match of the recipient area and the simplicity
of the technique. The literature was relatively quiet until in 2009 when Vinh et al.
reported on 103 supraclavicular flaps over an 8-year period supporting the reliabil-
ity (Vinh et al. 2009).
A 2012 review of 45 consecutive patients who underwent SAI flap reconstruc-
tion demonstrated success with the mean flap dimensions of 6.1 cm by 21.4 cm
long. The review reported partial skin flap necrosis in eight patients with two having
complete loss of the skin paddle. The authors noted that flap length greater than
22 cm was associated with flap necrosis (Kokot et al. 2013). The flap is relatively
quick to harvest, with surgical times under an hour, reliable repair of defects without
the need for performing microvascular anastomosis. However, one of the limitations
of the SAI flap is the arc of rotation. A 2017 review demonstrated an overall success
of 96.7% with only 10% of cases resulting in minor complications. The minor com-
plications included distal flap necrosis, donor site dehiscence, recipient site dehis-
cence, fistula, and wound infection (Trautman et al. 2018).

13 Submental Island Flap (SIF)

Martin et al. first described a new axial-patterned island flap based on the submental
artery in 1993 (Martin et al. 1993). The authors described a technique performed on
20 cadavers and eight patients who underwent radical neck dissection. The submen-
tal island flap consists of thin, pliable tissues with a good color match and wide arch
of rotation, and the authors noted a reliable long pedicle of up to 8 cm that can be
used as a cutaneous, musculofascial, or osteocutaneous flap.
Surgical Flaps 301

The submental island flap is based on the submental artery which is a branch off
the facial artery that has a typical diameter of 1–2 mm (9). In 1996, Sterne et al.
described the retrograde variant and recommended that when a flap is raised in a
reverse flow manner a separate venous anastomosis should be performed (Sterne
et al. 1996). Sterne used this technique for oral squamous cell carcinoma. In 1997,
Yilmaz et al. explained the de-epithelialized osteomuscular variant which is when
the superficial epithelial layer of the flap was removed and only the bone and muscle
were incorporated into the subcutaneous tunneled defect. The submental vessels run
deep to the anterior belly of the digastric muscle in up to 70% of patients and should
be included in the flap, but as stated in Yilmaz and Martins study, not including the
anterior belly of the digastric muscle does not result in flap failure (Yilmaz et al.
1997). Kitazawa et al. in 1999 described the bipedicled flap, where the flap incorpo-
rated two vessels which is advantageous in that it provides a robust circulation of the
flap and enabled them to reconstruct the upper lip as a unit safely. The drawback to
this technique is the two pedicles result in a restricted range of rotation (Kitazawa
et al. 1999). Patel et al. introduced the mylohyoid component to the flap harvest
(Patel et al. 2007). The modification provides protection to the distal submental
pedicle and cutaneous perforators adding reliability to the flap (Zenga et al. 2019).
Ramkumar et al. described the bi-paddled modification for increased bulk in
2012 (Ramkumar et al. 2012). There are two main uses for the submental artery
flap. The first is de-epithelization of a portion of the flap and the second is a full-­
thickness flap that is split into two paddles. With the second method, the skin inci-
sion is made to ensure the perforators located on either side of the anterior belly of
the digastric are included in the distal paddle. Ramkumar et al. find this advanta-
geous to the de-epithelization of a portion of a flap, but there is waste of valuable
skin area, less mobility, and de-epithelization and folding that can lead to inclusion
cysts (Ramkumar et al. 2012). Today, this technique is used for many defects in the
head and neck. Free flaps were mostly reserved for complex head and neck defects.
SIF is quickly emerging as an important technique due to its shorter operation and
patient recovery times (Jørgensen et al. 2019). This technique is comparable to the
radial artery free flap with shorter length of hospital stay and has been recommended
for defects in the oral cavity less then 40 cm (squared) (Conroy and Mahaffey 2009).

14 Facial Artery Musculomucosal Flap (FAMM)

Many intraoral techniques aided in the discovery and report of the facial artery mus-
culomucosal flap. It began when Tipton first described the closure of large septal
perforations with a labial buccal flap in 1965 (Tipton 1970). Years later, Jackson
utilized buccal flaps for closure of a secondary palatal fistula in 1972 (Jackson
1972). Kaplan then used buccal transposition flaps to line the nasal surface of the
soft palate in reconstruction in 1975 (Kaplan and Kaplan 1975). With the success of
these surgeons, Rayner described the extended use of mucosal flaps in the midface
302 S. Halepas and S. H. Troob

with his patients (Rayner 1984). Finally, Bozola et al. provided the first description
of an axial buccal musculomucosal flap based on the buccal artery for resurfacing
oral mucosal defects in 1985 and again in 1989 (Bozola et al. 1989). In 1983, Sasaki
et al. reported a case of a correction of cervical esophageal stricture using an axial
island cheek flap (Sasaki et al. 1983). Sasaki’s report led to Castens et al. to describe
the anteriorly based buccinator myomucosal island flap for an oroantral fistula
repair in 1991 (Carstens et al. 1991).
The term “facial artery musculomucosal flap” comes from Pribaz et al. who
described it in 1992 based on this knowledge base (Pribaz et al. 1992). The FAMM
flap consists of mucosa, submucosa, a small amount of buccinator muscle, the
deeper plane of the orbicularis oris muscle, and the facial artery/venous plexus. The
flap can be based superiorly (retrograde) or inferiorly (antegrade). When based
superiorly, the FAMM flap can be used to close maxillary defects such as mucosal
defects of the hard palate, alveolus, antrum, nasal floor, and septum as well as the
orbit. Inferiorly, the flap can be used to close defects of the posterior hard palate,
soft palate, tonsillar fossa, floor of the mouth, and even the lower lip. Pribaze et al.
described this technique with success in 15 patients.
The FAMM has several advantages as it avoids an external scar, provides a great axis
of rotation and range, is thin and pliable, provides a fully functional mucosal tissue, and
is a suitable reconstructive option even in radiated patients (Berania et al. 2018). By
2013, a total of 441 FAMM flaps were reported in the literature with the most common
site being the floor of the mouth. In a recent systematic review of 376 reported FAMM
flaps, the rate of partial and complete flap necrosis was 12.2% and 2.9%, respectively,
suggesting this flap is highly dependable (Ayad and Xie 2015). The FAMM flap has
some disadvantages. Many recommend the utilization of a bite block after surgery to
avoid biting of the pedicle by dentate patients. Two-stage procedure is required to sec-
tion the pedicle in dentate patients although some modifications do exist to avoid a
section procedure to section the pedicle. This is also a bulky flap that may hinder the use
of dental prosthesis if used in vestibular reconstruction (Ayad and Xie 2015).

15 Tissue Engineering

While the concept of tissue engineering is outside the scope of this chapter, the
authors felt it a necessary topic to discuss as the future of head and neck reconstruc-
tion. The history of tissue reconstruction began by borrowing or recruiting tissue
from local, regional, and then distant sites to fill defects. With advances in molecu-
lar and cell biology, surgeons may 1 day be able to reconstruct these areas using
tissues grown exclusively for this purpose, with exact matching form, function, and
aesthetics of that area. Many methods are being studied, but current research uses
skin tissue engineering with keratinocytes that are seeded onto bioactive scaffolds
(Tarassoli et al. 2018). The scaffolds allow adequate perfusion and cellular prolif-
eration/differentiation to produce tissue that mimics the defect site. With advance-
ments in this technology, doctors will be able to regrow tissues that exactly mimic
the tissue that was destroyed by resection or trauma.
Surgical Flaps 303

16 Summary

Reconstruction of the head and neck is extremely challenging due to the limited
access and complex anatomy. Fortunately, the robust vasculature has resulted in
successful surgical flaps as excellent options to restore form and function. The sur-
gical flap designs today rely on basic surgical technique and anatomical understand-
ing that dates to almost 800 BCE.
Several factors have aided in the evolution of this discipline, most significantly
trauma from war, knowledge exchange, and technological advancements in micro-
surgery. It is hard to believe that it was less than 50 years ago that G. Ian Taylor and
Ronald Daniel did the first successful free flap transfer in a human in 1973. In 2021,
with advanced computer-aided virtual surgical planning, microvascular reconstruc-
tive surgeons are benefiting from shorter operating room times, shorter hospital
stays, and overall decreased morbidity and mortality. The next steps for tissue defect
repair are with bioengineering.

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Microneurosurgery

Benjamin Palla, Preston Dekker, and Michael Miloro

“The patient is never to be abandoned to his sufferings.”

– John Collins Warren (1829)
“Although the interests of clinicians in peripheral nerve
injuries seems to wax in wartime and wane when peace comes,
the peripheral nervous system has few rivals in the fascination
it has exerted over the minds of workers in many fields of
medical science.”
– Sir Herbert Seddon (1943)
“The resolving power of the unaided eye does not permit an
appreciation of the problem nor a true appraisal of nerve
suture.”
– James W. Smith (1964)

1 First Accounts of Peripheral Nerve Surgery

Prior to the twentieth century, most nerve injuries were left unrepaired. The surgical
conditions were not ideal for such delicate and precise surgery required for suturing
the epineurium, let alone in identifying the various neural layers. If a nerve injury
received the attention of a surgeon, it was most likely for ablative purposes only.
However, there have always been surgeons willing to endeavor on behalf of the
treatment of patients with debilitating diseases, for which nerve damage is certainly
one of these, with significant effects on quality of life.
Before nerves could be transected and repaired, they had to first be identified.
Herophilus of Chalcedon (335–280 BCE) is credited for first identifying nerves,
by differentiating nerves from tendons. The work was expanded further by the well-­
known physician, Galen of Pergamon (CE 121–200), who described nerve injuries
in an interesting group of patients known as the gladiators (Galen of Pergamon
1576). Galen may also be the first physician to experiment on nerves as he tran-
sected the recurrent laryngeal nerve in pigs and described the weakening or loss of
voice he observed after transecting unilateral or bilateral nerves.

B. Palla (*) · P. Dekker · M. Miloro

Department of Oral & Maxillofacial Surgery, University of Illinois at Chicago,
Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 309

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_17
310 B. Palla et al.

Courageous efforts were also made in a time when little was known of nerve
physiology. Ambroise Paré (1510–1590) performed a nerve transection for King
Charles IX after he developed a contracture from bloodletting. He took advice from
surgeons such as Guy de Chauliac (1300–1368), physician to Pope Clement, and
Lanfranc of Milan (1250–1306), the father of French surgery – first to suggest the
primary repair of nerve injuries.
However, the first detailed description of peripheral nerve repair was provided by
an Italian surgeon named Gabriele Graf Von Ferrara (1543–1627) in 1596 (Artico
et al. 1996). During Ferrara’s life, the Renaissance was blossoming across Europe,
and the Italian Peninsula was the epicenter, with a significant study of anatomy and
surgery. Just prior to Ferrara, Leonardo da Vinci (1452–1519) completed his ana-
tomic works and dissections, and the year of Ferrara’s birth, Andreas Vesalius
(1514–1564) published his classic work, De Humani Corporis Fabrica Libri Septem
(1543). Ferrara joined the Brothers Hospitallers of Saint John of God and worked at
the Ospedale Fatebenefratelli in Milan in 1591, taking his vows and becoming
known as “Fra Gabriello.” Soon afterward, Ferrara published the first version of
what would become his defining contribution to the study of peripheral nerve repair
entitled, “Nova selva di cirugia di divisa in due parti,” in 1596 (Ferrara 1596). This
“due parti” soon became a “tre parti” with the release of his second edition, for
which he provided details of the following: (1) surgery, (2) medicaments, and (3)
figures of nerve treatment (Fig. 1).
Ferrara provided exquisite details of his surgical studies. Working 400 years ago,
it is fascinating to read his descriptions now and imagine working in similar condi-
tions (Fig. 2). In his work, Ferrara describes his stepwise process of identifying the
nerve stumps, dissecting them away from surrounding soft tissues, and ensuring that
the proper length of nerve was available so repair could occur without significant
tension. Following the realignment of the nerve stumps, gentle suturing was done
using a small needle and a suture made of turtle gut dipped in a concoction of red
wine, roses, and rosemary. After, a hot oil mixture of herbaceous plants was applied.
The surgery was followed by a period of rest and immobilization for the patient. In
addition, like many nerve surgeons who would come after, Ferrara traveled to aid
soldiers injured during war, which, for him, was at the Battle of White Mountain
during the Thirty Years’ War. He traveled extensively to aid patients, performing
work in Rome, Krakow, Vienna, Prague, Trento, and Trieste. The skull of Ferrara
can still be found at the Klosterkirche der Barmherzigen Brüder in Vienna, which he
founded, in addition to the Hospital of the Barmherzigen Brüder, now the largest
and oldest hospital in Vienna.
For centuries that followed, most surgeons avoided interventions related to mala-
dies involving nerves. One of the first to advocate for surgical resection of neuromas
was English surgeon William Wood (1783–1858), an audacious proposal at the
time (Wood 1829). Yet, he was surpassed by fellow Englishman, Joseph Swan
(1791–1874), and French surgeon, Alfred L.M. Velpeau (1795–1867), who would
propose an even more radical idea for their time that divided nerves should be
repaired (Swan 1834; Velpeau 1841).
John Collins Warren (1778–1856) provided an early publication on the treat-
ment of peripheral nerves in the Boston Medical and Surgical Journal in 1829
Microneurosurgery 311

Fig. 1 The title page from Ferrara’s 1596 “Nova selva di cirugia; divida in due parti”
312 B. Palla et al.

Fig. 2 Instruments used

by Ferrara to perform his
nerve repair

(Warren 1829). JC Warren, son of John Warren (1753–1815), founding member of

Harvard Medical School, was himself a prolific physician, surgeon, and academi-
cian. JC Warren helped found The New England Journal of Medicine, Massachusetts
General Hospital, and the Warren Anatomical Museum – currently housed in
Harvard’s Countway Library, which not only houses the skull of Phineas Gage but
the skeleton of JC Warren as well. He was the first Dean of Harvard Medical School
and the first surgeon to operate on a patient using general inhalational anesthesia,
provided by the dentist William T.G. Morton (1819–1868), a previous partner to
the dentist Horace Wells (1815–1848).
Warren was one of the first to describe a stepwise approach in treating peripheral
nerve pain and neuralgias, specifically trigeminal neuralgia. This process began
with identifying the specific nerve and then performing medical treatment for a
6-week duration – which included a combination of iron carbonate, iron sulfate,
belladonna, conium, hyoscyamus, stramonium, opium, cinchona, sulfate of quinine,
calomel, leeches, bloodletting, cupping, blistering, moxa, caustic potash, and other
Microneurosurgery 313

hot fomentations. In the cases of ongoing neuralgia, a surgeon should then intervene
and excise a portion of the nerve, preferably a healthy portion, and the more proxi-
mal the better.
Similar to Ferrara, Warren noted observations that appeared almost prophetic
despite the lack of knowledge related to nerve physiology during his era. Specifically,
speaking on the temporal relation between injury and treatment, Warren said,
“When the disease is of longstanding, neither excision nor amputation of the limb is
to be relied upon: for the whole course of the nerve becomes diseased.” He stated
surgery would have better success if performed “within a few weeks of the origin of
the disease.” Yet, like others working before the availability of Nylén’s surgical
microscope, he was limited by magnification, stating that the “membrane lining the
fibrils, -a part so minute, that we can scarcely expect to support the opinion by
observation” (Warren 1829).
A breakthrough in the understanding of neurophysiology came with the observa-
tions of Augustus Volney Waller (1816–1870), an English neurophysiologist. It
was his 1850 paper that described what is now known as “Wallerian degeneration.”
In the study, Waller transected the glossopharyngeal and hypoglossal nerves in frogs
and studied the outcome histologically (Waller 1851). He observed that the distal
nerve inevitably degenerated, while the proximal segment would remain healthy.
Such a phenomena was noted in 1795 by surgeon William C. Cruickshank
(1745–1800), but this observation was not fully appreciated by scientists of that era
who believed that nerves are healed by “reunion” and not by this proposed cellular
process of degeneration followed by “regeneration” (Cruikshank and Hunter 1795).
The credit for performing the first successful nerve resection for trigeminal neu-
ralgia is given to John Murray Carnochan (1817–1887), an American surgeon
practicing in New York (Carnochan 1859). He operated on three patients with unre-
lenting pain of the infraorbital region, all who had previously been treated with
medical therapy similar to JC Warren’s approach above. In 1856, under chloroform
anesthesia, Carnochan exposed the maxilla in these patients in an approach similar
to the Weber Ferguson incision and resected the entirety of the maxillary branch of
the trigeminal nerve up to the foramen rotundum. The first patient, a 69-year-old
French physician, underwent surgery a day after meeting Carnochan. The surgery
was successful, and seemingly immediate, as the French physician “ordered chicken
broth, and wine and water” after resection. Remarkably, all three of these records of
trigeminal nerve resection were successful, and no recurrence of trigeminal neural-
gia was noted by Carnochan.
Significant advancement in the understanding of nerve repair is often attributed
to the experiences working with injuries during the American Civil War (1861–1865),
specifically to the work of Silas Weir Mitchell (1829–1914). Mitchell was a physi-
cian in Philadelphia and previous acquaintance to the Union’s Surgeon General,
W.A. Hammond (1828–1900). Hammond established a unit at the Turner’s Lane
Military Hospital in Philadelphia that would focus on nerve injuries and amputa-
tions. Hammond appointed Mitchell to what would colloquially be called “Stump
Hospital.” Mitchell is considered by many as the father of neurology and coined the
314 B. Palla et al.

term “causalgia,” now known as complex regional pain syndrome (CRPS). Mitchell
provided his experiences at “Stump Hospital” in two books, one in 1864 and the
other in 1872, that significantly impacted future physicians and surgeons (Mitchell
et al. 1864; Mitchell 1872).
Across the Atlantic Ocean, Jean Joseph Émile Létiévant (1830–1884) was also
publishing an immense 548-page treatise on nerves, published in 1873 (Létiévant
1873). In these pages, Létiévant cited articles in five different languages and
described one of the first records of nerve repair. Prior to this, most surgeons dealt
with nerves only as far as performing nerve resections for relief of neuralgia.
Létiévant described the use of metallic sutures to repair nerve injuries, specifically
one related to the ulnar nerve in 1869. His book described nerve sections, résec-
tions, suture, autoplasty, and greffe as well as a “tingling sign” when percussing
over some repaired nerves – but he neglected the significance of this as most during
this time period did not believe nerves could regenerate. Shortly after, a German
field surgeon Bernhard von Langenbeck (1810–1887) successfully repaired a
median nerve in 1876 (Langenbeck 1876).
Although a growing number of surgeons were attempting nerve repair, the surgi-
cal technique was limited to re-aligning the proximal stump with the distal segment.
In order to accomplish this, nerves were often stretched, liberated, and transposed,
and the bony joints were flexed, sometimes allowing up to 8-cm gaps to be bridged
(Davis and Cleveland 1934). These techniques showed little concern for the delete-
rious effects of tension on the nerve repair site. Performance of the first nerve graft
is credited to J.M. Philipeaux and Alfred Vulpian (1826–1867), who performed
their pioneering work in 1863 and 1870 (Philipeax and Vulpian 1863, 1870). In the
initial study, the surgeons cut the hypoglossal and lingual nerves in a dog; then,
using an optic nerve from a separate recently deceased puppy, they bridge the hypo-
glossal nerve to the lingual nerve. Although the connection was re-established and
opened avenues of future practice, the dog unfortunately died. The second study by
Philipeaux and Vulpian described seven attempts at nerve autografts, with two of
these being reported as successes. In these dogs, a 2-cm segment of the hypoglossal
and lingual nerves was excised. The lingual nerve segment was then utilized to
reconnect the stumps of the hypoglossal nerve. In two puppies, movement was later
reported in the distal tongue, both spontaneously and with the use of galvanized
stimulation. Upon animal sacrifice and histologic examination, new nerve fibers
were observed bridging the nerve repair sites.
In 1873, a German surgeon named Eduard Albert (1841–1900) would attempt
to advance the works of Philipeaux and Vulpian, attempting the first nerve graft in
humans (Albert 1887). In his 1887 book, Albert describes two patients, one with a
median nerve injury and the other with an ulnar nerve injury. Albert resected the
nerve lesions back to a healthy proximal and distal stump and then used a recently
amputated lower limb from separate patients to acquire a tibial nerve graft: a length
of 3 cm in the first patient and 10 cm in the second patient. He sutured the nerve
ends with catgut via a direct and indirect technique; however, as we may expect with
our current knowledge of immunology, both grafts soon failed. Four years later,
Microneurosurgery 315

Albert did perform a nerve graft experiment in dogs, exchanging the right and left
sciatic nerves, in which case he reported success, with some recovery of motor
function.
Building upon these creative techniques of nerve repair and nerve grafting,
Themistocles Gluck (1853–1942) is credited with the first use of nerve entubula-
tion, performed in 1881 (Gluck 1881). For this procedure, Gluck used an absorbable
decalcified bone tube, developed by Gustav Adolf Neuber (1850–1932) initially
for the use as a surgical drain in 1879 (Neuber 1879). Gluck described bridging a
severed nerve with this Neuber tube, but unfortunately the attempt failed. A success-
ful attempt was performed the same year however, but this was achieved by
Constant Vanlair (1839–1914) (Vanlair 1882). On September 30, 1881, Vanlair,
who witnessed Gluck’s procedure, resected a 3-cm segment of the sciatic nerve in a
dog and bridged the defect with a 4-cm version of Neuber’s decalcified bone tube.
Vanlair reported the dog later regained mobility and a microscopic exam after the
animal at time of sacrifice showed the presence of bridging nerve fibers.
Although some, such as the father of neurosurgery Harvey Cushing (1869–1939),
would write about their experiences with peripheral nerve surgery, comments may
be limited to a few case descriptions (Cushing 1983, 1903). A significant advance-
ment body of work was when Henry Head (1861–1940) and James Sherren
(1872–1945) began to focus on peripheral nerve injuries at the London Hospital in
1905 (Head and Sherren 1905). Focusing on peripheral nerve repair of the hand,
they were among the first significant studies on a large population using objective
criteria. Post-operative patients were evaluated utilizing instruments that remain
extremely familiar to us in the twenty-first century: a cotton wool brush for detec-
tion of light touch, a compass to discriminate two points, a blunt pencil for pressure,
a hot or cold glass tube for temperature, a tuning fork for vibration, and a sharp
needle for pain.
Head and Sherren described in great detail the recovery pattern of injured nerves.
After the initial anesthesia, pain and temperature sensation returned first, followed
months later by “higher forms of sensibility” such as light touch. They took Weir-­
Mitchell’s term “causalgia” and coined the term “hyperalgesia” to describe the
“exaggeration of sensibility to pain” (Head and Sherren 1905).
Yet, Head was frustrated with what seemed to him to be unreliable patient
descriptions of their pain and sensation. In his 1908 book with William Halse
Rivers Rivers (1864–1922), Head relied on the only person he could definitely
trust – himself. On April 25, 1903, Head allowed Mr. Sherren and an assistant Mr.
Dean to make a 6.5-inch incision of his left forearm to remove a segment of the
nerve from both his N radialis and N cutaneous antebrachial lateralis, placing two
silk sutures in both nerves for realignment (Rivers and Head 1908). The book,
which contained 450 pages and 19 photos of Head’s hand, characterized the details
of this experiment over the next 5 years (Fig. 3).
Through the work of Head and Sherren, surgeons began to differentiate vari-
ous nerve insults and how they affected recovery – complete division, partial
division, or blunt trauma. They were also adept in noting the sensation of “pins
and needles” or “tingling” that some patients described after a nerve operation.
316 B. Palla et al.

This later description is one which would be fully elucidated a decade later by
two physicians during the WWI, although they were from opposite sides of the
battlefield.
The German physiologist Paul Hoffmann (1884–1962) and the French neu-
rologist Jules Tinel (1879–1952) described their observations only 6 months
apart in 1915 during the WWI (Tinel 1915; Hoffmann 1915a). Their description
became known as the “Tinel-Hoffmann Sign.” Eager surgeons rounding on their
patients only days after operation attempted various methods to determine the
likelihood of successful repair and neurosensory recovery, a visual depiction of
surgeons that remains true today. Both Hoffmann and Tinel noted that by tap-
ping with light percussion just distal to the site of nerve injury and repair, some
patients would experience a tingling sensation radiating in the distribution of the
sensory nerve. If this occurred, it was considered a positive sign and a prognos-
tic indicator that nerve regeneration was occurring across the site of repair or
injury. In Hoffmann’s paper, he even calculated a rate of regeneration based on
the location of percussion and tingling, calculated as 2.25 mm/day in 1915
(Hoffmann 1915b). However, with the loss of Germany in WWI and WWII,
much of Hoffmann’s work was censored and unknown to the Western medical
establishment for decades, finally translated to English in 1993 (Hoffmann
et al. 1993).
Also performing nerve repair during WWI was William Wayne Babcock
(1872–1963), an American surgeon (Babcock 1907). While operating on failed
nerve repairs, Babcock noted a physical scar that seemed to mechanically obstruct
the regenerating nerve fibers. This finding had been noted by prior surgeons, but
Babcock was one of the first to give significant attention to preventing scar forma-
tion at the site of repair. He promulgated a belief of performing “nerve dissocia-
tion” in such cases, later termed “hersage,” which involved incising the nerve
sheath and separating out the individual nerve fibers or “skeletonizing” the nerve
(Babcock 1907).

Fig. 3 Photograph from

the 1908 book by Henry
Head and William HR
Rivers. This photo displays
the left hand and forearm
of Head, who allowed
Rivers to perform a nerve
resection so he could study
the recovery pattern.
Incision site and scar are
visible on the proximal
forearm
Microneurosurgery 317

2 Development of Microneurosurgery

After WWI, advances in peripheral nerve surgery continued, in large part to the
design and implementation of the first surgical microscope by Carl-Olof Siggesson
Nylén (1892–1978). Nylén, in addition to being an Olympic tennis player, was an
otolaryngologist and considered the father of microsurgery. Nylén described the
development of what was first called an “otomicroscope” implemented in 1921
(Nylen and Person 1922).
Nylén first used a monocular microscope designed by Brinell to repair labyrin-
thine fistulas of the inner ear. The Brinell microscope had a magnification of
10–15X, but soon after Nylén designed a monocular microscope with an engineer
N. Person (1922) that could achieve a magnification of 120X. The same year, Zeiss
and Gunnar Holmgren, to whom Nylén was an assistant surgeon, designed the first
binocular surgical microscope. The binocular microscope became widely popular-
ized, and continual improvements to working distance, field of view, and illumina-
tion have occurred (Nylen 1954).
The implementation of the surgical microscope coincided with an immense
increase in the knowledge of nerve physiology and regeneration. Santiago Ramón
y Cajal (1852–1934), a 1906 Nobel laureate with Camillo Golgi, described the
axonal cone, neurotropism, and the degeneration and regeneration model of nerves
in his 1928 book (Ramon y Cajal 1928). In 1930, Sterling Bunnell, the father of
hand surgery, reported the first successful autogenous nerve graft of the facial nerve
(Bunnell 1937). In 1934, Loyal Davis reviewed nerve repair techniques from nerve
implants, nerve flaps, suture à distance, tubulization, nerve crossing, and nerve
transplants or grafts (Davis and Cleveland 1934). Davis was keen to observe the
difficulty in acquiring autogenous grafts of similar caliber that also had low donor
site morbidity. He, like others, saw the potential in nerve allografts as an alternative,
but it would be many years before an understanding of their immunogenicity pro-
gressed for this alternative to be realized.
In 1942, Herbert John Seddon (1903–1977), an English orthopedic surgeon at
Oxford, described a classification for nerve injuries that remains the foundation of
modern practice today (Seddon 1942). Seddon initially described three types of
lesions of nerves which were classified by morphologic and clinical behavior: first,
“neurotmesis” (division of a nerve), a “cutting” or separation of the nerve with com-
plete loss of sensation and motor function and low likelihood for spontaneous
recovery; second, “axonotmesis” (lesion in continuity), a complete separation of
nerve fibers with complete peripheral degeneration, but intact sheath and supporting
structures, and high likelihood of spontaneous recovery; and third, “neuropraxia”
(transient conduction block), a short-lived paralysis from disturbed nerve conduc-
tion without axonal degeneration. In his paper and speeches (Seddon 1943), Seddon
also discussed treatments for each type of nerve injury and was an advocate for
surgical exploration, even if only to incise the most fibrotic area in nerve lesions in
order to evaluate for the presence of nerve fibers.
318 B. Palla et al.

Seddon’s classification of nerve injuries was soon updated by Australian Sydney

Sunderland (1910–1993) in 1951 (Sunderland 1951). Sunderland, who was the
Chair of Anatomy at the University of Melbourne, based the classification scheme
on his detailed understanding of the peripheral nerve anatomy. Sunderland’s main
focus was to provide further clarification on the wide spectrum of Seddon’s “axo-
notmesis” category. Sunderland provided “five degrees of nerve injury,” from least
to most severe, based upon the anatomy of the axon, axonal sheath (Schwann cell,
neurilemma, endoneurium), funiculus (perineurium), and epineurium (Fig. 4).
“First-degree” injuries were associated with no anatomic disturbance, but simply
a compromised conduction of the nerve, equivalent to Seddon’s “neuropraxia.”
Seddon’s “axonotmesis” was divided into second-, third-, and fourth-degree inju-
ries. “Second-degree” injuries involved only the axons. “Third-degree” injuries dis-
rupted the axon and the axonal sheath. “Fourth-degree” injuries disrupt the axons,
axonal sheath, and funiculus, only leaving the epineurium intact. “Fifth-degree”
injuries are a complete separation of all anatomical nerve structures, equivalent to
Seddon’s neurotmesis. Wallerian degeneration was described to be present in sec-
ond-, third-, fourth-, and fifth-degree nerve injuries. Many years later, Mackinnon
and Dellon would describe a “sixth-degree” injury that would account for the fact
that some injuries may have mixed components of various degrees of injury
(Mackinnon and Dellon 1988).
However, both Seddon and Sunderland should not simply be remembered for
their classification systems. Both performed significant research related to nerve
physiology and repair techniques that future generations would build upon. In 1943,
Seddon already calculated the average nerve regeneration rate of 1.5 mm/day
(Seddon 1943). Seddon established the Peripheral Nerve Injury Centre within the
Department of Orthopedics at the University of Oxford, within which Peter Medawar
started his career developing a plasma to connect nerves without the use of sutures;
Medawar later received the 1960 Nobel Prize for his contributions to grafting and
immune tolerance (Young and Medawar 1940). Sunderland also published

Fig. 4 Schematic representation of nerve anatomy and the various degrees of nerve injury. Above
the figure are the classifications systems of Seddon and Sunderland with their associated degree of
nerve damage
Microneurosurgery 319

immensely and wrote a landmark text on nerve injuries and repair (Sunderland
1968). Both Seddon and Sunderland were knighted for their contributions.
Also working in Seddon’s Peripheral Nerve Injury Centre was W. Bremner
Highet, who contributed significantly to our understanding of how tension affected
the outcomes of nerve repair (Highet and Holmes 1943; Highet and Sanders 1943).
Prior to his studies in 1943, the standard technique of nerve repair was twofold: (1)
preparation of healthy stumps and (2) tension-free, end-to-end alignment. This
method is similar to that used today; however, prior to the 1940s, most large defects
achieved tension-free closure via mobilization of the nerve and some degree of joint
flexion. For instance, in the first article by Highet and Holmes, a patient required
resection of an 11.5-cm segment of the lateral popliteal nerve. To close the nerve
gap, Highet mobilized the nerve from the surrounding tissue (1.5-cm gain in nerve
length), extended the hip (1-cm gain in nerve length), and then flexed the knee to
100° (9-cm gain in nerve length). The knee was held in this flexed position via a cast
for 23 days, after which it was slowly straightened over 60 days. Highet noted that
in five of their six cases treated by this methodology, no recovery occurred, and
when histologic exam was performed, no nerve fibers crossed the repair site (Fig. 5).
Highet and Sanders confirmed this study in dogs, removing a portion of the
external popliteal nerve and then flexing the knee to achieve an end-to-end

Fig. 5 Working in
Seddon’s Peripheral Nerve
Injury Center, W Bremner
Highet displayed the poor
results from joint flexion
and the subsequent
extension of nerves that
lead to significant tension,
failure, and scarring
320 B. Palla et al.

re-­approximation. The dogs were placed in casts for 14 days, after which a rapid or
passive extension of the knee was performed. In both groups, the postoperative
stretching of nerves led to separation of the stumps, edema, fibrosis, and degenera-
tion. Nerves did not lengthen, and the fibrosis around the repair site became adher-
ent to the surrounding tissues in all animals. The authors discussed two future
possibilities. First, implement the use of amnioplastin, which in 1941 Robert
Lambert had used to prevent scarring of peripheral nerves to the surrounding tissue
(Rogers 1941). Secondly, improve and implement novel nerve grafting techniques.
Yet, despite this progress, results from surgical interventions did not occur ini-
tially, and nerve repair outcomes at this time remained poor. Mackenzie and Woods
showed in 1961 that only 50% of patients recovered from repair of the median nerve
(Mackenzie and Woods 1961), which were similar to findings of the Medical
Research Council in 1954 under Seddon (1954).
In the 1960s, a varied group of peripheral nerve surgeons, most working in the
upper extremities and hands, began to inquire about ways to improve nerve repair
techniques. Surgeons saw the improvement their peers in microvascular surgery
were experiencing with the use of the surgical microscope. Microscopes had not
been used in peripheral nerve surgery up to this time. James W. Smith was an early
advocate for the implementation combined with new instruments used by those in
the jewelry and diamond cutting field (Smith 1964). At this time 7-0 silk and 8-0
nylon sutures were being used, cutting needles, and methylene blue for contrast.
Smith seemingly proved the benefit of the surgical microscopes by performing the
repair of the sciatic nerve in rabbits, one side by the unaided eye and the other by
microscope.
Hanno Millesi (1927–2017) was an Austrian plastic surgeon who spent his
career focusing on repair of peripheral nerves of the arm (Millesi 1973). Like Smith,
he was also an early proponent of using the surgical microscope for nerve repair.
Millesi is often credited with first describing the interfascicular suture technique in
1968 (Millesi 1968). At this time, Millesi proposed using only perineurial nerve
sutures, and the epineurium at the stumps was removed to prevent scarring.
Nerve repair of the head and neck specifically benefited from the work of a
German group led by Jarg-Erich Hausamen, a German oral and maxillofacial sur-
geon. Along with Berger, Meissl, Samii, and Schmidseder, this group focused on
the repair and reconstruction of the facial nerve, inferior alveolar nerve (IAN),
accessory nerve, and lingual nerve. In one study, Hausamen took five groups of rab-
bits to compare IAN repair and reconstruction techniques (Hausamen et al. 1974).
The results were overwhelming and clearly showed that the autologous nerve graft
group performed significantly better compared to the other four (nerves cut or
resected with and without direct suture re-approximation). This study supported
previous findings showing a high success of the use of the sural nerve as a graft for
IAN reconstruction (Hausamen et al. 1973).
Bruce Donoff and Walter Guralnick from Harvard School of Dental Medicine
and Massachusetts General Hospital discussed repair of the IAN and lingual nerve
in 1982 (Donoff and Guralnick 1982). Using previous studies with dogs, they
Microneurosurgery 321

discussed the benefit of delayed primary repair (1–3 weeks after injury) and second-
ary repair (several weeks to months after injury) based upon the degeneration and
regeneration nerve models.

3 Contemporary Practice of Microneurosurgery

The practice of peripheral nerve surgery as it is performed today consists of the

cumulative work and endeavors of the pioneers mentioned above. Many advance-
ments continue to occur in contemporary practice, with new innovative techniques
specific to peripheral nerve repair in the hand and extremities that are beyond the
scope of this chapter. However, with regard to peripheral nerve repair of the head
and neck region, and specifically of the trigeminal nerve and its terminal branches,
other surgical specialties have balked at addressing these injuries. The field of oral
and maxillofacial surgery has stepped into this void and accepted responsibility for
this complex anatomic field and difficult surgical environment. Perhaps one reason
oral and maxillofacial surgeons may have become interested in these injuries is due
to the significant number which occur iatrogenically within the field of dentistry,
most commonly from the third molar removal in the mandible (Pogrel and Thamby
1999). Due to the unexpected nature of many of these injuries, a large aspect of
recent research endeavors has been aimed to better evaluate the risks associated
with nerve injury. It has been estimated that nearly 40% of patients with trigeminal
nerve injuries are involved with medico-legal litigation (Pogrel and Thamby 1999).
First, a comment on the current terminology in practice today. “Nerve repair”
refers to the procedure when two native nerve ends are sutured directly to each other
head to head, such as in a direct repair after neurolysis. The term “nerve reconstruc-
tion” is a nerve surgery that uses a nerve graft, either autogenous nerve graft or
allograft nerve, that is placed between two native nerve ends to bridge and recon-
struct a defect. Finally, the term anastomosis is more specific to the repair of arterial
or venous vessels and not appropriate for use with nerves.
In current dentoalveolar surgery practice, the vast majority of nerve injuries
occur following third molar surgery. The risk of injury is estimated at 0.5–5.0% for
the IAN and 0.6–2.0% for the lingual nerve during third molar extraction (Pogrel
and Thamby 1999). Patients undergoing orthognathic surgery, maxillofacial trauma,
or oncologic reconstruction may have a higher incidence, but oftentimes these
patients are more accepting and understanding of sensory deficits. In recent decades,
the development of dental implants has been associated with another iatrogenic
cause of neurosensory injury pertaining specifically to the IAN.
In order to evaluate the proximity between the inferior alveolar nerve and the
mandibular third molar, a landmark study was published in 1990. Rood and Shehab
presented seven radiographic signs visible on panoramic radiographs that are asso-
ciated with a close proximity between the roots of the mandibular third molar and
IAN (Rood and Shehab 1990). Three of the seven radiographic signs were
322 B. Palla et al.

significantly associated with nerve injury, which included diversion of the canal,
interruption of the corticated white line of the mandibular canal, and darkening of
the root – the latter being the most significant.
Efforts were also made to determine the location of the lingual nerve. In 1984,
John Kiesselbach and Jack Chamberlain performed dissection on cadavers, find-
ing the lingual nerve located at 2.28 mm inferior and 0.58 mm medial from the
lingual crest and plate in the third molar region (Kiesselbach and Chamberlain
1984). The authors also reported direct contact with the lingual plate in 62% of
cadavers, with the nerve located above the level of the crest in 17.6% of cadavers.
This article was followed in 1997 by Michael Miloro, whose group used MRI in ten
living subjects that displayed the average lingual nerve that was located 2.75 mm
inferior and 2.5 mmmedial to the lingual crest and plate, with 10% above the crest
and 25% in contact with the lingual plate (Miloro et al. 1997).
In recent years, an additional cause of nerve injury that has become more promi-
nent is the occurrence of nerve injury after routine nerve blocks. A significant
amount of research initially went to distinguishing the relevance of two potential
causes, namely, the trauma that occurs from needle penetration of a nerve and that
of the toxicity from the local anesthesia drug. Using rat sciatic nerve however,
Hillerup and colleagues displayed significant evidence indicating that the primary
factor of injury was related to the high concentration of local anesthesia (4%), rather
than from needle trauma alone (Hillerup et al. 2011).
In 1989, G.E. Ghali and Bruce Epker provided a high-impact article on clinical
neurosensory testing (NST) as it relates to the trigeminal nerve (Ghali and Epker
1989). Later studies by John Zuniga have evaluated the accuracy of these various
methods for NST: two-point discrimination and brush stroke direction (Level A),
static light touch (Level B), and nociception via temperature or pinprick (Level C)
(Zuniga et al. 1998). Roger Meyer, who speculated on the poor outcomes of nerve
repair when delayed over 1-year at the American Association of Oral and
Maxillofacial Surgery Meeting in 1991, later provided the evidence base in 2010
with Zuniga (Bagheri et al. 2010). Interestingly however, M. Anthony Pogrel
showed only 10% of these patients undergo surgical intervention (Pogrel 2002).
The work of both Susan Mackinnon and A. Lee Dellon has brought significant
advancement to nerve repair starting in the 1980s. Although innovating new tech-
niques for nerve repair particularly for limbs, Mackinnon and Dellon modified the
British Medical Research Council Scale for assessing nerve repair, originally pub-
lished in 1954 by Sir Seddon (1954). They specifically developed the guidelines for
assessing sensory function in the extremities (Mackinnon and Dellon 1988). This
guideline was later adapted and applied to assessing the recovery of the trigeminal
nerve by Thomas Dodson and Leonard Kaban (1997). The assessment will pro-
vide a grading scale ranging from S0 (no recovery) to S4 (complete recovery).
Mackinnon and Dellon are also credited with advancing the entubulation method
developed in 1881 by Themistocles Gluck, implementing polyglycolic acid bioab-
sorbable tubes and comparing the results of the repair with autogenous sural nerve
grafts (Pogrel 2002; Mackinnon and Dellon 1990). Prior to this, autogenous nerve
grafts were the most common means of nerve repair and are still considered by
Microneurosurgery 323

many to be the gold standard. Given the diameter of the trigeminal nerve, the graft
most often used for reconstruction was the sural nerve. Recent research from these
authors have shown great benefit in the use of processed human nerve allograft and
connected-assisted repair. The nerve allografts can now be ordered in a variety of
lengths and diameter.
Today, nerve reconstruction of the head and neck with the use of allograft is
slowly replacing autogenous grafts. Allografts have a few noted benefits, most nota-
bly avoiding a second surgical site and the associated morbidity. In addition,
improvement in grafting materials and techniques has led to nearly equivalent or
improved results between allografts and autografts (Safa et al. 2020; Miloro
et al. 2015).
The work of Ralph Merrill and Phillip Worthington, who attended a course by
Dr. Hausamen and Dr. Reuter at the University of Washington in Seattle in 1979,
could be seen as a new era for the study of trigeminal nerve injuries and repair
(Merrill 1979). These surgeons educated a lineage that has been proficient in the
literature over the last 40 years and is still active today. In January 2018, the first
oral and maxillofacial surgeons joined the American Society of Peripheral Nerve
Surgery, those being Shahrokh Bagheri, Michael Miloro, and John Zuniga.
In recent decades, the field of microneurosurgery for the trigeminal nerve has
experienced a significant expansion in evidence base. However, the field still
remains in its infancy in many ways. The future of peripheral nerve repair will likely
involve regeneration of the peripheral nerves through neurotropic factor manipula-
tion in the microenvironment and other still unseen avenues of treatment. The
knowledge in this field is now enough to comprise the first edition of the textbook
in itself in 2013, “Trigeminal Nerve Injuries,” with future editions to follow the
progress of this field (Miloro 2013).

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Temporomandibular Joint Surgery

Kenneth Kufta, Peter D. Quinn, and Eric J. Granquist

1 Introduction

The history of temporomandibular joint (TMJ) surgery encompasses a list of many

successful and unsuccessful attempts at re-establishing form and function and
decreasing pain in the orofacial region. The first TMJ surgeries were thought to be
performed in BC, primarily for treatment of pathologies such TMJ ankylosis and
dislocation (Indresano and Mobati 2006). The first documentation of an intra-­
articular TMJ procedure is by Annandale in 1887, during which he performed a disc
repositioning procedure for treatment of closed lock (Annandale 1887). Over the
next several hundreds of years, the pendulum of surgical tenets, approaches, and
options offered to patients with TMJ disease swung widely. This included a strong
movement that promoted nonsurgical treatments after many catastrophic outcomes,
followed by the use of alloplastic implants which had previously been shown to
have poor biocompatibility. More recently, oral and maxillofacial surgeons (OMS)
have played a major role in innovating devices and techniques in TMJ surgery
through appropriately designed clinical trials, demonstrating highly effective surgi-
cal options for patients. Some of these procedures include TMJ disc excision with
or without autogenous replacement, TMJ disc repositioning, autogenous costochon-
dral TMJ reconstruction, stock and custom prosthetic TMJ replacement, as well as
minimally invasive procedures such as arthrocentesis and arthroscopy. In this chap-
ter, we will explore the history of different TMJ surgical techniques, as well as
highlight landmark articles that resulted in the field of contemporary TMJ surgery
that continues to evolve today with the advent of advanced technology. While we

K. Kufta · P. D. Quinn · E. J. Granquist (*)

Department of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA, USA
e-mail: [email protected]; [email protected];
[email protected]

© The Author(s), under exclusive license to Springer Nature 327

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_18
328 K. Kufta et al.

attempt to arrange this chapter in chronological order in regard to when the tech-
niques were developed, the history of TMJ surgery is convoluted, and thus organiza-
tion is quite challenging.

2 Gap Arthroplasty/Discectomy/Disc Repositioning

While ancient cultures were familiar with certain TMJ pathologies such as ankylo-
sis of joints and jaw dislocation, there was no documentation of surgical treatment
of these disease processes until the late 1800s. TMJ ankylosis was first treated via
simple gap arthroplasty, but this procedure was often complicated by re-ankylosis
(Topazian 1966). John Murray Carnochan, a prominent New York surgeon, is
praised for his ideology of inter-posing a material (a block of wood) between the
bony surfaces of the mandible and temporal bone after gap arthroplasty for treat-
ment of TMJ ankylosis (Carnochan 1860). Soon thereafter, many different surgeons
used this same principle of gap arthroplasty with inter-positional grafting for treat-
ment of TMJ ankylosis.
While Gluck first made use of an Ivory prosthetic stabilized with cement to
bridge the gap in 1891 (Gluck 1891), Murphy was the first to use temporalis fascia
as an inter-positional graft for gap arthroplasty (Murphy 1913). In 1914, he pub-
lished a case series in which he described his use of an axial rotational inter-­
positional flap of temporal fat and fascia to line the TMJ with the goal of restoring
joint function and preventing re-ankylosis (Murphy 1914). Since then, surgeons
have attempted to use many different types of inter-positional materials to restore
function and range of motion, including temporalis muscle (Risdon 1933), gold foil
(Risdon 1933), tantalum foil (Eggers 1946), stainless steel (Smith and Robinson
1952), dermis (Georgiade et al. 1957), full thickness skin (Popescu and Vasiliu
1977), and in the modern era, silastic and polytetrafluoroethylene (PTFE) a.k.a.
Teflon materials.
Perhaps one of the darkest ages of TMJ surgery lies in the years during which
silastic and Teflon implants began to be placed within the joint in the 1960s. At the
time, silastic materials were known for their high thermal stability as well as their
relative inertness within the human body (Mercuri 2016). Silicone was first used as
an inter-positional material in 1968 during reconstructive hand surgery (Swanson
1997). Subsequently, Brown et al. reported on the use of silicone material to serve
as a barrier in preventing TMJ ankylosis after gap arthroplasty (Brown et al. 1963),
and others reported similar techniques (Robinson 1968). Short-term studies revealed
that the silicone implants would incite formation of a reactive fibrous capsule that
could possibly serve as a new disc while helping to prevent re-ankylosis (Brown
et al. 1963; Spagnoli and Kent 1992).
Unfortunately, by the 1980s, studies began to describe significant complications
related to silastic materials placed within the TMJ. Severe inflammatory foreign
body reactions with associated regional lymphadenopathy as well as erosion of con-
dylar heads were described in multiple reports (Dolwick and Aufdemorte 1985;
Temporomandibular Joint Surgery 329

Eriksson and Westesson 1986; Hartman et al. 1988). Further studies even revealed
that fragmented silicone particles had migrated within the regional lymphatics
(Hartman et al. 1988). Additional follow-up studies were published conveying poor
results associated with silastic implants within the TMJ (Eriksson and Westesson
1992). After review of a multitude of studies demonstrating the negative conse-
quences of the implantation of silicone materials into the joint space, the American
Association of Oral and Maxillofacial Surgeons (AAOMS) published a consensus
paper recommending that the use of permanent silastic implants be discontinued
(American Association of Oral and Maxillofacial Surgeons 1993a). The publication
of these results was preceded by a workshop in 1992, during which AAOMS orga-
nized a meeting consisting of OMS experts, nonsurgical clinician experts in manag-
ing TMJ disorders, and biomaterial experts tasked with developing a consensus on
the use of alloplastic inter-positional materials within the TMJ. The experts devel-
oped a consensus stating that silastic implants should no longer be permanently
placed in the TMJ as an inter-positional material (American Association of Oral and
Maxillofacial Surgeons 1993a). However, silastic implants have continued to be
used as temporary spacers after arthroplasty and disc excision. The workshop also
made detailed recommendations regarding the need for removal of implants and
follow-up intervals (American Association of Oral and Maxillofacial
Surgeons 1993a).
Around the same time that silastic materials began to be used for reconstruction
of the TMJ, surgeons such as Small also began to report on their use of PTFE as a
material for joint reconstruction after large mandibular resections (Small et al.
1964). PTFE was found to have a high density as well as a self-lubricating property,
which was believed to be suitable for a ginglymoarthrodial joint such as the
TMJ. Despite prior studies demonstrating Teflon fragmentation under loading that
resulted in significant foreign body reactions (Charnley 1963), Cook proceeded to
use Teflon as an alloplastic inter-positional material in the TMJ in 1972 (Cook 1972).
Later in that decade, Vitek Inc. (Houston, TX) began to fabricate implants in
which Teflon was combined with other materials. In the 1960s, a chemical engineer
by the name of Charles Homsy designed a material named Proplast, which was
originally intended for use in orthopedic surgery. Given its porous nature and thus
potential for tissue ingrowth and implant stabilization, it was thought to be suitable
for use as an inter-positional material in TMJ surgery (Homsy 1970; Homsy et al.
1972). Proplast I (PTFE + carbon/graphite) was first developed, followed by
Proplast II (PTFE + aluminum oxide) to allow for more neutral coloration of
implants placed superficially (Westfall et al. 1982). Again, despite several studies
demonstrating the presence of giant cells and macrophages around these intra-joint
materials (Homsy et al. 1973), others continued to use Proplast implants within the
TMJ and reported short-term successful outcomes (Kirsch 1984; Wade et al. 1986;
Bee and Zeitler 1986). However, it was not long until there were widespread studies
reporting on the deleterious effects of Teflon-based materials placed within the TMJ.
The most notable complications included severe condylar degeneration (Florine
et al. 1986; Bronstein 1987), remodeling/erosion of condylar and glenoid fossa
bony structures (Heffez et al. 1987), implant fragmentation (Heffez et al. 1987), and
330 K. Kufta et al.

foreign body giant cell reactions in regional lymph nodes (Lagrotteria et al. 1986).
Additional longer-term studies demonstrated similar negative clinical and radio-
graphic outcomes in patients with prior implantation of Teflon materials within the
TMJ (Morgan 1988; Kaplan et al. 1988; Schellhas et al. 1988). As clinical symp-
toms were delayed compared to radiographic signs, patients soon began reporting
symptoms including preauricular pain and swelling, limited mouth opening, occlu-
sal changes, lymphadenopathy (Wagner and Mosby 1990), and even perforation
into the middle cranial fossa (Fig. 1) (Berarducci et al. 1990).
Eventually, studies published by El-Deeb et al. and Valentine et al. demonstrated
evidence of fragmentation of the Proplast implants with associated significant

a b

Fig. 1 (a) Coronal and (b) sagittal view of a CT scan demonstrating a Proplast implant within the
TMJ resulting in erosion into the middle cranial fossa. (c) Explanted Proplast with evidence of
significant wear leading to material perforation and implant fragmentation
Temporomandibular Joint Surgery 331

foreign body reactions composed of active giant cells/osteoclasts that resulted in

severe degeneration of adjacent bony structures (El Deeb and Holmes 1989;
Valentine Jr. et al. 1989). Wagner and Mosby also published a long-term study
revealing 95% of patients with Proplast implants reporting severe pain, along with
100% of cases with condylar degeneration (Wagner and Mosby 1990). In light of
the plethora of studies revealing potential negative consequences associated with
implantation of Teflon substances in the TMJ, the FDA and Center for Devices and
Radiological Health issued a Public Health Advisory in September 1991 regarding
the recall and close monitoring of patients with previously placed Teflon implants
within the joint (Johnson 1991). In 1992, this was followed by the release of a TMJ
Implant Advisory sent to all OMS regarding the published data revealing the nega-
tive outcomes seen in patients implanted with Proplast-Teflon materials (American
Association of Oral and Maxillofacial Surgeons 1992). Further evaluation of pub-
lished studies on the topic resulted in an AAOMS-sponsored workshop that pub-
lished recommendations for discontinuation of Proplast-Teflon as an inter-positional
implant for the TMJ, as well as either removal of the implant with reconstruction
using autogenous tissue or close monitoring with yearly CT and/or MRI evaluation
(American Association of Oral and Maxillofacial Surgeons 1993b). As a result of
these devastating results associated with Teflon-Proplast implants, very strict mea-
sures have appropriately been put in place to rigorously investigate the use of any
further materials to treat pathologies of the TMJ. Furthermore, these failed materi-
als were shown to having lasting consequences, as it has been shown that TMJR
outcomes are less likely to be successful after Proplast-Teflon implant failure (Henry
and Wolford 1993).
In addition to treatment of ankylosis, surgical methods and approaches began to
focus on treatment to improve symptoms of internal derangement of the TMJ. As
such, discectomy became one surgical treatment modality, originally described by
Lanz in 1909 (Lanz 1909) and further popularized by Pringle (1918) and Ashhurst
(1921). Although the discectomy procedure was found to have favorable results in
follow-up studies (Boman 1947; Dingman and Moorman 1951), there was a signifi-
cant amount of controversy over its use given the uncertainty regarding the patho-
physiology of disease within the TMJ. It wasn’t until Bowman published his
dissertation (Bowman 1947), and other long-term follow-up studies were published
(Eriksson and Westesson 1985; Holmlund et al. 1993; Silver 1984) that discectomy
became a broadly accepted, effective treatment modality for TMJ pathologies.
Although the discectomy became standard of care by the 1970s (Dingman and
Moorman 1951; Kiehn and Desprez 1962), there was still controversy regarding the
necessity of replacing the disc with autogenous versus alloplastic materials to pre-
vent recurrent disease/ankylosis. Several long-term follow-up studies have shown
success with discectomy without replacement of the disc (Holmlund et al. 1993;
McKenna 2001). However, surgeons continued to search for a disc replacement
material due to concerns regarding persistent joint noise, crepitus, and condylar
resorption seen in patients who had underwent discectomy without replacement
(Dimitroulis 2011a). In 1958, Gordon had described his technique of replacing the
intra-articular disc with polyethylene caps to prevent re-ankylosis and collapse of
332 K. Kufta et al.

vertical dimension (Gordon 1958). In addition to their use as inter-positional mate-

rials for gap arthroplasty, alloplastic materials such as silastic and Teflon were also
used to replace discs. In light of the disastrous complications resulting from insert-
ing these materials within the TMJ, surgeons began to search for autogenous grafts
to serve as an articular disc replacement (Dimitroulis 2011a). Expanding upon
Murphy’s use of the temporalis fat-fascia axial flap for management of TMJ anky-
losis (Murphy 1913, 1914), Dimitroulis introduced the use of abdominal dermis-­fat
as an inter-positional graft for use in ankylotic patients (Dimitroulis 2004). Given its
relative success, Dimitroulis also introduced the concept of using abdominal der-
mis-fat grafting after TMJ discectomy and demonstrated its ability to survive and
withstand the intra-articular forces (Dimitroulis et al. 2008). Fat grafting alone after
discectomy was not shown to prevent additional bony morphological changes in the
mandibular condyle (Dimitroulis 2011b), and it has been found to significantly
decrease in size over time in orthopedic studies (Kanamori et al. 2001). While der-
mis-fat grafting has been shown to resist the reduction in size of the grafting as seen
with fat alone (Dimitroulis et al. 2008), prevent ankylosis (Dimitroulis et al. 2008),
and result in overall improvement in quality of life (Dimitroulis et al. 2010), severe
condylar changes after its placement in the joint have prevented its regular use
(Dimitroulis 2011b).
Additional autogenous materials used as a disc replacement include temporalis
muscle flaps (Feinberg and Larsen 1989; Pogrel and Kaban 1990), auricular carti-
lage (Matukas and Lachner 1990), and dermis grafts (Meyer 1988; Dimitroulis
2005). Given studies that have shown fragmentation of the grafts, low survivability,
and inability to prevent condylar changes, there has not been a graft that has shown
adequate strength or biologic compatibility in serving as a replacement for the TMJ
articular disc (Dimitroulis 2005; Yih et al. 1992; Sandler et al. 1997). Animal stud-
ies comparing meniscectomy alone versus different disc replacement grafts have
largely demonstrated similar clinical outcomes in regard to pain relief, improve-
ment in mouth opening, and osteoarthritic changes of the condyle with or without
replacement. Histologic studies revealed that discectomy alone does not result in
regeneration of the disc, but rather arthritic condylar changes along with replace-
ment of the articular surfaces by infiltration of adjacent fibrovascular tissue (a
pseudo-disc) (Tong and Tideman 2000). Discectomy with replacement using autog-
enous grafting demonstrated an extensive fibrotic response without survival of the
graft. Given these results and similar clinical outcomes in human studies comparing
discectomy alone versus discectomy plus replacement with graft, the decision
whether or not to replace the disc remains controversial (Dimitroulis 2011a).
In addition to complete removal of the disc, other approaches including reposi-
tioning of the disc were attempted. While Annandale performed the first disc repo-
sitioning procedure in 1887, the concept of this surgical method for the treatment of
internal derangement was not well-supported until Wilkes described the form and
function of the TMJ in his arthrographic studies (Mehra and Wolford 2001; Wilkes
1978a, b). McCarty described the classic disc repositioning method of performing a
high condylar shave with disc release and repositioning by suturing to the posterior
Temporomandibular Joint Surgery 333

attachments (McCarty and Farrar 1979). Leopard described posterior repositioning

of the disc via suturing of the disc to the inferior aspect of the temporalis fascia
(Leopard 1984). Walker and Kalamchi recommended condyloplasty with freeing of
the articular disc, which allowed for suturing of the disc to the lateral capsule in a
new position atop the condylar head (Walker and Kalamchi 1987). Eventually,
Weinberg demonstrated successful outcomes in meniscocondylar plication for disc
repositioning, which provided the foundation for the idea of the Mitek mini anchor
(Weinberg and Cousens 1987). In 1993, Wolford et al. developed a technique in
which a bone anchor, named a Mitek mini anchor (DePuy Synthes Mitek Anchor,
Raynham, MA, USA), is implanted into the posterior condylar head and subse-
quently sutured to reposition and stabilize the articular disc (Fig. 2) (Cottrell and
Wolford 1993). Since this time, the FDA has approved its use in patients for the
treatment of internal derangement of the TMJ. Additional bone anchors, including
the JuggerKnot Mini Soft anchor (Zimmer BioMet, Warsaw, IN, USA) (Hanley
et al. 2015) and the Arthrex Corkscrew anchor (Arthrex Inc., Naples, USA) (Ryba
et al. 2015), have also been developed for use in TMJ disc repositioning surgery.
TMJ ankylosis, along with internal derangement, served as the primary patholo-
gies that led to the development of partial and total reconstruction of the joint.
Although gap arthroplasty with inter-positional grafting for TMJ ankylosis has been
shown to promote improved joint range of motion compared to gap arthroplasty
alone (Ma et al. 2015), many studies have shown variable results in regard to re-­
ankylosis and restoration of function (Topazian 1966) (Ramezanian and Yavary
2006; Zhi et al. 2009). This, along with incomplete resolution of symptoms after

Fig. 2 Insertion of
JuggerKnot Mini Soft
anchor into the condylar
head for the purpose of
TMJ disc repositioning
334 K. Kufta et al.

discectomy/disc repositioning in the case of internal derangement, inspired sur-

geons to develop techniques for excision with TMJ reconstruction of joint articula-
tion with both autogenous and alloplastic materials.

3 TMJ Reconstruction: Autologous and Alloplastic

The history of TMJ reconstruction includes unfortunate catastrophic failures and

recent success. The goal of TMJ reconstruction is to restore form and function. In
addition, the primary goal should focus on improving quality of life for the patient.
Loss of TMJ functionality most often results from ankylosis, internally deranged
joints/osteoarthritis, high inflammatory arthritides, as well as less common etiolo-
gies such as congenital abnormalities and neoplastic processes. The constant daily
use of the TMJ, as well as the complex physiology of a joint that is capable of both
rotational and translational movements, creates a significant hardship in effectively
restoring form and function via reconstruction. A plethora of both autologous and
alloplastic materials have been used to partially and totally reconstruct the TMJ.

3.1 Autogenous

Several different autologous grafts have been used to attempt to reconstruct the TMJ
(Lindqvist et al. 1986; MacIntosh and Henny 1977). In 1909, Lexer was the first to
describe the use of “joint allotransplantation,” during which he used a costochondral
graft to reconstruct a proximal tibia after excision of a sarcoma (Lexer 1909;
Nikolaou and Giannoudis 2017). Bardenheur is then credited as the first surgeon to
replace the mandibular condyle with an autograft (fourth metatarsal) in 1909 (Lexer
1925), while Gillies is well-known for being the first to reconstruct the TMJ with a
costochondral allograft (MacIntosh and Henny 1977; Gillies 1920). The use of an
osteochondral allograft was promising, as it allowed for the use of an avascular tis-
sue to replace both hyaline cartilage and a significant bony deficiency.
Since this time, surgeons have attempted to use many different types of auto-
grafts for TMJ reconstruction, including iliac, metatarsal, tibial, fibula, and sterno-
clavicular tissues (Smith and Robinson 1952; Entin 1958; Dingman and Grabb
1964; Plotnikov 1965; Ware and Taylor 1966; Snyder et al. 1971). The uses of these
autografts have had variable results, specifically given their inconsistent adaptabil-
ity and lack of growth potential (Poswillo 1974). Most surgeons have collectively
agreed that the costochondral graft functions best as a replacement of the mandibu-
lar condyle given its biological and physiological similarities, along with low donor
site morbidity (Lindqvist et al. 1986; Freihofer and Perko 1976; Kennett 1973).
Furthermore, biologic studies were carried out to prove superiority of the costo-
chondral graft compared to other autografts, given its proliferative nature as well as
its remodeling and growth properties (Poswillo 1974; Blackwood 1966; Durkin
Temporomandibular Joint Surgery 335

et al. 1973). Long-term follow-up studies have also confirmed the efficacy of costo-
chondral grafts for TMJ reconstruction (Lindqvist et al. 1988; Perrott et al. 1994;
Figueroa et al. 1984). Resnick et al. also recently developed a consensus regarding
the use of costochondral grafts and other surgical modalities in the specific treat-
ment of patients with juvenile idiopathic arthritis (JIA) (Resnick et al. 2019).

3.2 Alloplastic

The safety and efficacy of alloplastic joints in the orthopedic literature encouraged
the OMS community to seek alloplastic implant options for their patients with
severe TMJ disease (Charnley 1961). While alloplastic TMJ replacement is now a
widely accepted procedure within the scope of OMS today, the history of placing
alloplastic implants within the TMJ is fraught with publications describing drastic
failures of materials such as the Kent-Vitek prosthesis (Vitek, Houston, TX, USA)
as well as the Christensen, Osteomed, and Delrin-Timesh prostheses (Mercuri 2016;
Driemel et al. 2009). One of the major advantages of alloplastic joint reconstruction
is that it afforded the surgeon the ability to efficiently and predictably restore form
and function to the TMJ without any donor site morbidity or need for maxilloman-
dibular fixation (Donlon 2000).
Eggers was the first to describe placement of an alloplastic material between the
mandible and cranium when he placed tantalum foil in the intra-joint space for the
treatment of ankylosis (Eggers 1946). Subsequently, Smith and Robinson published
on the use of a stainless steel fossa (Robinson 1960; Smith and Robinson 1957),
while Henry published on the use of stainless steel as a means of replacing the man-
dibular condyle (Henry 1960). Ward, who also popularized the modified condylot-
omy approach for the treatment of TMJ internal derangement, published on the use
of cobalt-chrome alloy to reconstruct the TMJ (Ward 1961). Notably in 1963, based
on Robinson’s method of creating a fossa prosthesis, Christensen designed a 0.5-­
mm Vitallium-based glenoid fossa eminence prosthesis to reconstruct the TMJ as
well as provide a mechanical barrier for prevention of re-ankylosis (Christensen
1963, 1964). With this method, Christensen fabricated castings of 20 different-sized
glenoid fossae prostheses made of rigid, polishable Vitallium that can be sized intra-­
operatively and anchored to the zygoma. Eventually, he expanded the stock of
casted prostheses to 33 per side and then 44 to broaden the surgeons’ reconstructive
options for anatomic variations (Fig. 3) (Christensen 1964). Eventually, Christensen
went on to describe the first total joint replacement device for the TMJ. The device
consisted of his previously described Vitallium fossa prosthesis along with a condy-
lar component made of cobalt-chrome (Co-Cr) alloy and a molded polymethyl-
methacrylate (PMMA) condylar head (Driemel et al. 2009; Christensen 1971). In
1996, he eventually discontinued the use of the PMMA head given reports of mate-
rial resorption under function (Mercuri 1996). Almost 5000 Christensen prostheses
had been implanted between 1993 and 2003, and their use continued until the FDA
ordered a cease and desist order in 2015 due to non-compliance with 522
336 K. Kufta et al.

Fig. 3 Original set of Christensen set containing 33 variations of stock prostheses for reconstruc-
tion of the TMJ

post-­market surveillance studies (Christensen 1971; TMJ 2021). Christensen also

eventually developed an all-cast-Vitallium custom total joint prosthesis using CAD/
CAM technology to treat more surgically and anatomically complex patients
(Garrett et al. 1997).
In 1971, Morgan described alternative fossa eminence prostheses that consisted
of a Vitallium eminence and eventually added a silastic articulating component
given the degenerative changes seen within the condylar head (Morgan 1971;
Morgan and Hall 1985). Eventually, the use of permanent silastic implants for TMJ
surgery was discontinued given the significant foreign body reaction observed in
patients (Eriksson and Westesson 1986; American Association of Oral and
Maxillofacial Surgeons 1993a). Soon thereafter, Morgan went on to develop his
own ramus-condyle replacement that consisted of an acrylic condylar head (House
et al. 1984; Morgan 1992). Kiehn is also credited for the development of a Vitallium
condylar-fossa prosthesis reinforced with PMMA (Kiehn et al. 1974).
Others had also reported on the idea of hemiarthroplasty, in which an alloplastic
condylar component functions against a natural disc/fossa without an alloplastic
fossa component. Authors have reported on the use of custom cast gold ramus-­
condyle units (Tauras et al. 1972), methyl methacrylate (Kameros and Himmelfarb
1975), Delrin (polyoxymethylene)-titanium (Boyne et al. 1987), Vitallium (Kiehn
et al. 1974; Silver et al. 1977; Hahn 1964), Vitallium with PMMA cement (Silver
et al. 1977), as well as the controversial Proplast-coated Ticonium condylar prosthe-
sis (Hinds et al. 1974). Despite studies on TMJ hemiarthroplasty demonstrating
successful outcomes with low complication rates (Marx et al. 2008), other studies
have discredited its use given the potential dreadful complication of severe bony
erosion into the cranial base (Lindqvist et al. 1992; Westermark et al. 2006).
In 1976, Spiessl attempted to decrease the risk of glenoid fossa resorption by
altering the condylar head design in his AO/ASIF system (Spiessl 1976). He
designed both short and long models of a condylar reconstruction plate (Prein
2002), although reports were still made describing erosions into the glenoid fossa
(Lindqvist et al. 2002). Attempts were made to make use of the AO/ASIF system
Temporomandibular Joint Surgery 337

while preserving the articular disc or in conjunction with lining the glenoid fossa
with a pedicled flap (Prein 2002; Klotch et al. 1998).
In 1972, Kent et al. published a pilot study describing the use of a condylar pros-
thesis with its head coated with Teflon-Proplast (Kent et al. 1972). Accordingly,
Kent added a Teflon-Proplast fossa prosthesis consisting of a Proplast superior layer
with a Teflon inferior layer (Kent et al. 1983), which collectively with the condylar
unit became known as the Vitek-Kent I (VK-I) total joint prosthesis. The Vitek-Kent
II (VK-II) was then subsequently described, which also included PTFE within the
fossa component (Kent et al. 1986).
Throughout the 1980s the Vitek-Kent prosthesis was commonly used as a means
for alloplastic joint reconstruction. During this time, Rooney et al. published a study
with concerning findings of significant foreign body reaction to PTFE resulting in
condylar degeneration (Rooney et al. 1988). Given the concerns for fracturing of the
Teflon-Proplast fossae resulting in significant foreign body reactions, the Teflon
portion of the Vitek-Kent prosthesis was eventually replaced with polyethylene.
Kent subsequently reported an update on the follow-up of the VK-I and VK-II pros-
theses, which had 80% success rate at 6 years and 20% success rate at 10 years
(Kent et al. 1993). Given the material failure of the Proplast-Teflon with associated
foreign body giant cell reaction, patients who had undergone reconstruction with
these devices underwent frequent imaging and follow-up to evaluate for the need for
device removal (Spagnoli and Kent 1992; Feinerman and Piecuch 1993). These
complications resulted in millions of dollars in claims and the official revoking of
prior FDA approval (Speculand et al. 2000). As such, TMJ devices were reclassified
as class III devices, suggesting the high risk posed to the patient and thus necessitat-
ing stringent pre- and post-market approval processes (FDA 2021).
After the devastating material failure of the Teflon-Proplast system, several other
surgeons set out to develop other materials for alloplastic reconstruction, including
ceramic implants (Szabo et al. 1990), titanium-based implants (Raveh et al. 1984;
MacAfee and Quinn 1992; Butow et al. 2001), and titanium-polyethylene combina-
tions (Sonnenburg et al. 1984; Sonnenburg and Sonnenburg 1990). Van Loon
reported biomechanical studies demonstrating the acceptable wear resistance of
metal-on-UHMWPE total TMJ prostheses (Van Loon et al. 1999, 2000). Others
attempted to expand upon the AO/ASIF with adjustable/add-on condylar prosthe-
ses, but placement and positioning of the device proved to be quite technically dif-
ficult (Driemel et al. 2007; Raveh et al. 1980; Vuillemin et al. 1989).
In the early 1990s, Mercuri made use of the emerging advanced technology by
developing the TMJ Concepts Prosthesis (Techmedica model) (Mercuri et al. 1995).
This model made use of pre-operative CT scanning and CAD/CAM technology to
fabricate custom condylar and fossa prostheses designed to fit the specific anatomy
of each patient. Its condylar component consisted of a titanium alloy mandibular
shaft with a cobalt-chromium-molybdenum (Co-Cr-Mo) condylar head, while its
fossa component consisted of a titanium mesh with an articulating surface com-
posed of ultra-high-molecular-weight polyethylene (UHMWPE) that is designed to
maximize contact with the condylar head (Fig. 4) (Mercuri 2000). Given the
338 K. Kufta et al.

extensive pre-operative surgical planning resulting in precise device fitting, the TMJ
Concepts facilitated the reconstruction of TMJs that have been undergone multiple
operations resulting in distorted anatomy (Mercuri et al. 2002; Wolford et al. 1994).
After long-term follow-up studies demonstrating successful results, the TMJ
Concepts prosthesis obtained FDA approval in 1999 (Driemel et al. 2009; Mercuri
et al. 2002). Others such as Butow (Butow et al. 2001) and Hoffman and Pappas
(Fig. 5) (Hoffman and Pappas 2000) had prostheses in development at the same
time, but ultimately did not receive FDA clearance. These devices had titanium
nitride at the condylar and fossa contacting surfaces to produce more wear-resistant
components.
Also in the 1990s, Quinn and Van Loon built upon the ideology of a stock metal-­
on-­polyethylene prosthesis to produce a more cost-effective, wear-resistant stock
prosthesis (van Loon et al. 2000, 2002; Quinn 2000). In 1995, Quinn introduced the
Biomet-Lorenz total joint stock prosthesis, which consisted of Co-Cr condylar
heads with titanium plasma spray coating of different lengths and widths and a
UHMWPE fossa of multiple flange sizes (Figs. 6 and 7) (Quinn 2000). This led to

Fig. 4 Custom TMJ

Concepts prosthesis with
Co-Cr-Mo condylar head
and titanium mesh +
UHMWPE fossa
component

a b

Fig. 5 Hoffman-Pappas device (a) implanted within the patient and (b) explanted
Temporomandibular Joint Surgery 339

Fig. 6 Original Biomet-­

Lorenz TMJ
replacement set

an investigational device exemption study published in 2012 demonstrating the

safety and efficacy of the Biomet-Lorenz stock prosthesis (Giannakopoulos et al.
2012), and the device was approved by the FDA in 2010. A recent FDA post-market
study by Granquist et al. revealed a similar survivorship rate and subsequent surgi-
cal intervention rate to that of other orthopedic joint replacements (Granquist
et al. 2020).

4 Arthroscopy

As TMJ surgery continued to evolve throughout the 1900s with many successes and
failures, OMS began to take notice of the orthopedic surgery literature and their
minimally invasive techniques of treating diseased joints. A long history of endo-
scopic procedures exists in the orthopedic literature, dating back to the first use of
an endoscope 1853. A French surgeon named Antoine Jean Desormeaux, now
known as the “Father of Endoscopy,” first demonstrated the use of an endoscope
(named the Lichtleiter) in a patient for a urology procedure (Indresano and Mobati
2006; Figdor 2004). The endoscope primarily functioned as a cystoscope until
1918, when Japanese surgeon Kenji Takagi described the use of a 3.5-mm
340 K. Kufta et al.

Fig. 7 Original design sketches by Dr. Peter Quinn demonstrating the biomechanical testing of
the load and cyclic compressive fatigue for the Biomet-Lorenz TMJ prosthesis

cystoscope to perform diagnostic arthroscopies of cadaver knee joints (de Mello

Granata Jr 2012). He subsequently helped design an arthroscope in 1920 and then
published a case series including photos of his knee arthroscopies (Indresano and
Mobati 2006; de Mello Granata Jr 2012). As additional studies were published
describing diagnostic techniques using the arthroscope (Kreuscher 1925) and tech-
nologic advances allowed for the development of smaller arthroscopes with
improved optics, TMJ surgeons took notice of this minimally invasive technique.
After the development of the small joint arthroscope by Watanabe in 1958
(Watanabe 1986; Watanabe and Takeda 1960) (Fig. 8), a Japanese surgeon by the
name of Ohnishi was the first to describe its use for performing a TMJ arthroscopy
in 1975 (Onishi 1975). As additional studies out of Japan by Murakami had
described arthroscopy as a minimally invasive, useful adjunct in the treatment of
patients with TMJ disorders (Murakami and Ono 1986; Murakami et al. 1986;
Temporomandibular Joint Surgery 341

Fig. 8 The original no. 21

arthroscope developed by
Watanabe in 1958
(Watanabe and Takeda
1960)

Murakami and Ito 1981, 1984), Sanders introduced the technique of TMJ arthros-
copy in the United States (Sanders 1986).
Subsequent clinical studies carried out by Sanders, Murakami, and McCain eval-
uated the efficacy of arthroscopy of the TMJ and solidified its diagnostic and thera-
peutic use in the United States (Murakami et al. 1986; Sanders and Buoncristiani
1987; McCain 1988; McCain et al. 1989). In particular, Murakami published on the
use of arthroscopy to evaluate joint adhesions (Murakami and Segami 1993), and
Bronstein demonstrated its use in determining disc position (Bronstein 1989).
McCain also published on advanced operative techniques in which the disc could be
manipulated and repositioned using arthroscopy (McCain et al. 1992a). McCain and
Sanders subsequently published a study describing high success rate of arthrosco-
pies of over 4800 TMJs in 1992 (McCain et al. 1992b), with additional studies
demonstrating high efficacy (Sanders and Buoncristiani 1993). Additional advanced
techniques including the use of sclerotherapy (Merrill 1993) and laser treatments
(Indresano and Bradrick 1993) were also developed and described. Further signifi-
cant technological advances have also been made to develop state-of-the-art arthro-
scopes specifically designed to improve upon visualization of the temporomandibular
joint space (Fig. 9). In a controversial surgical field troubled by the recent failure of
alloplastic materials in TMJ replacements, TMJ arthroscopy served as an initial,
safe, inexpensive, effective means of treating TMJ disease via lysis and lavage and
offered an option to patient to potentially spare an open procedure.

5 Arthrocentesis

Evidence of the first “arthrocentesis” as a treatment for intra-joint fluid accumula-

tion dates to the sixteenth century, during which it was described in the Aztec litera-
ture. During this time, the technique of simple paracentesis was often performed to
treat joint effusions (Emmart 1940; Rodnan et al. 1966). In 1792, a French surgeon
by the name of Jean Gay described the successful outcomes associated with his
technique of paracentesis along with injection of “medication” into a knee joint.
With the intention of decreasing inflammation, Gay injected a mixture of wine,
brandy, and rum into the knee joint of two separate patients, noting a significant
post-operative improvement in symptoms (Rodnan et al. 1966).
342 K. Kufta et al.

Fig. 9 Contemporary Karl

Storz model all-in-one
TMJ arthroscope system

In 1947, Schultz was the first to describe injection into the TMJ. He injected
sodium psylliate into the periarticular region with the intent of stimulating a fibrotic
response to limit condylar mobility in order to treat joint hypermobility (Schultz
1947). In 1950, McKelvey demonstrated successful patient outcomes of his own by
injecting sclerosing solutions into the periarticular region of the TMJ to treat sub-
luxation (McKelvey 1950). Later in 1987, Murakami et al. published on their use of
arthrocentesis in the treatment of closed lock. Their team described a technique of
readjusting the mandible while inducing hydraulic pressure with lidocaine in the
upper joint space with a 21-gauage needle (Murakami et al. 1987). Nitzan, Dolwick,
and colleagues then built upon Murakami’s technique by describing the lavage of
the TMJ with lactated ringers by placing two separate needles (one used for inflow,
the other for outflow) into the superior joint space. They described successful results
in patients with trismus, with lavage resulting in improvement in pain scores,
improvement in maximal incisal opening, and lasting symptom relief (Nitzan et al.
Temporomandibular Joint Surgery 343

1991). Although initially only used for acute closed lock, TMJ arthrocentesis is now
used for a variety of conditions associated with the joint including disc displace-
ment, synovitis, rheumatoid arthritis, disc adhesions, and hemarthrosis, with other
medications such as steroids, anti-inflammatories, and lubricating agents commonly
being injected.

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Distraction Osteogenesis

Dani Stanbouly and Michael Perrino

1 Introduction

Distractions osteogenesis, the biological process of new bone formation between

gradually separated bone segments through incremental traction, has very early
roots. The renowned Greek physician, Hippocrates, was reported to have mechani-
cally manipulated bone fragments in the repair of fractures. Subsequently, Guy de
Chauliac in the fourteenth century first utilized continuous traction in the repair of
fractures through a pulley system that consisted of a weight attached to the leg by a
cord. Years later in the twentieth century, an Italian surgeon named Alessandro
Codivilla illustrated one of the earliest instances of external fixation, where he
induced limb lengthening of the lower limb through external skeletal traction after
an oblique osteotomy of the femur. His device consisted of a traditional plaster cast
placed on the leg and cut in half at the level of the osteotomy. While the proximal
part of the cast was fastened to a stationary external frame, the distal part of the cast
was anchored to the calcaneus via a pin (Samchukov et al. 1998).
Thereafter, distraction osteogenesis quickly increased in popularity across the
world and was implemented particularly for the purpose of limb lengthening.
Nevertheless, its successes were accompanied with an equal degree of complica-
tions, namely, bone-associated problems such as delayed healing, non-unions, and
deformities and soft tissue-associated problems due to overstretching, such as nerve
palsy. These significant issues stopped the process of distraction osteogenesis from
achieving universal acceptance. While many surgeons responded to the

D. Stanbouly
College of Dental Medicine, Columbia University, New York, NY, USA
M. Perrino (*)
Riverside Oral Surgery, River Edge, NJ, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 353

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_19
354 D. Stanbouly and M. Perrino

complications that erupted with the increasing popularity of distraction osteogene-

sis overtime, none of them addressed them as effectively as the Russian surgeon,
Gavriil Ilizarov. He developed a fixation apparatus that held several advantages over
the widely recognized methods at the time. Ilizarov also developed a revolutionary
technique called subperiosteal corticotomy for the purpose of limb lengthening. The
procedure ensured maximum preservation of the periosteum and endosteum, deliv-
ering minimum trauma to the periosteum and to the bone marrow (Samchukov
et al. 1998).
It is worth mentioning that in his clinical experience, Ilizarov came to discover a
couple of biological principles in distraction osteogenesis: (1) the tension-stress
effect on the genesis and growth of tissues and (2) the influence of blood supply and
mechanical loading on the shape of bones and joints. On top of his theoretical dis-
coveries, Ilizarov articulated the practical circumstances necessary for their effec-
tive implementation through a series of experiments on dogs. His experiments
scrutinized several phenomena and illustrated many novel and valid notions. In
investigating the effect of the direction of distraction on the orientation of newly
formed tissues, Ilizarov discovered that the regenerated bone always formed along
the axis/direction of applied traction (Fig. 1). When he explored the influence of the
rate and rhythm of distraction on the formation of the bone, his results proved that
more frequent rates of distraction led to more favorable regeneration with less soft
tissue problems. Despite the innovation that shone through his work, Illizarov
remained by and large unknown to the rest of the world until his surgical expertise
was requested by the famous Italian alpinist, Carlo Mauri. Carlo Mauri suffered
from a foot deformity that could not be treated by the world’s leading surgeons, who
saw nothing more than a poor prognosis that rested on amputation. Ilizarov’s

Fig. 1 G.A. Ilizarov’s

low-energy subperiosteal
corticotomy technique.
(Reprinted with permission
and without alterations
from Cope et al. (1999),
Original Figure 5)
Distraction Osteogenesis 355

successful work on Carlo Mauri gained the attention of Italian surgeons, who invited
Ilizarov to educate them on his methods. There, the Association for the Study and
Application of the Method of Ilizarov (ASAMI) was formed. Subsequently, conti-
nental and international districts of ASAMI were formed to foster the exchange of
knowledge about different aspects of distraction osteogenesis (Samchukov
et al. 1998).

2  arly Applications of Distraction Osteogenesis

E
in Maxillofacial Surgery

The arrival and development of distraction osteogenesis in the field of maxillofacial

surgery were possible through the lessons learned from its application on long
bones by the surgeons who pioneered the technique, such as Gavriil Ilizarov (Cope
et al. 1999). Nevertheless, the time to transfer the knowledge acquired from distrac-
tion osteogenesis of the long bones to the maxillofacial region took over 40 years
(Erverdi and Motro 2015).
During the early twentieth century and prior, skeletal deformities of the cranio-
facial complex, such as maxillomandibular hypoplasia, facial asymmetry, and con-
genital micrognathia, have been addressed in terminally grown patients via
osteotomies followed by acute orthopedic movements and skeletal fixation. In order
to correct retrognathic mandibles, Brown in 1918 and Bruhn-Linderman in 1921
each performed a vertical osteotomy of the mandibular body followed by acute
advancement of the anterior segment, where the consequent gap created would be
filled by healing bone regenerate (Limberg 1925). While this paradigm of acute
treatment, embodied by orthognathic surgery, has achieved notable success, it has
several limitations (Caldwell and Amaral 1960; Converse and Horowitz 1969). One
of these limitations is the inability of soft tissues, such as the muscle, to accommo-
date the abrupt mechanical changes in bone position. Partial or total relapse often
results secondary to the acute stretching of the muscle, and/or the forces applied by
the myofascial system to the osteotomized segments and intervening bony regener-
ate. Unless additional surgery accounts for this limitation from large movements or
movement vectors that violate the myofascial compartment, stability to the planned
reconstruction goal will be compromised (Longaker and Siebert 1996). As a
response to the deficits of orthognathic surgery in the correction of the skeletal
deformities mentioned earlier, the procedures within this paradigm of gradual treat-
ment, characterized by distraction osteogenesis, were attempted in the maxillofacial
region and achieved promising results as compared to traditional orthognathic sur-
gery (Cope et al. 1999).
According to Loboa et al., the daily tension produced by the distraction device
causes just enough trauma to the tissues to induce neoformation of mesenchymal
tissues without critical damage (Loboa et al. 2004). The triggered bone regeneration
comes about through a cascade of biological processes which may include
356 D. Stanbouly and M. Perrino

differentiation of pluripotent cells, angiogenesis, osteogenesis, and bone mineral-

ization (Rachmiel and Shilo 2015). The first instance of distraction osteogenesis in
the maxillofacial region was performed by Wolfgang Rosenthal in 1927. This
“primitive” attempt was followed up by the father of modern plastic surgery,
Varaztad H. Kazanjian, who was consulted by a patient with retrusion of the chin
that was not correctable through the orthodontics measures taken (Fig. 2). Of note,
Kazanjian was an oral surgeon by training. Kazanjian performed L-shaped osteoto-
mies on both sides of the mandible and attached a wire hook directly to the man-
dibular symphysis. Three days post-operatively, an “over the face” appliance (Fig. 3)
was placed and activated with an elastic band that was attached to the wire hook,

Fig. 2 A photo of the patient who presented to Kazanjian due to a patient with retrusion of the
chin. The patient initially presented with severe malocclusion that was corrected through ortho-
dontics as is illustrated here. (Reproduced with permission and without alteration from Kazanjian
(1941), Figure 11)
Distraction Osteogenesis 357

Fig. 3 On the left is an illustration of the “over the face” appliance utilized by Kazanjian. On the
right is a picture of the patient post-operation. Her retrusion of the chin, refractory to orthodontics,
was fixed through Kazanjian’s treatment plan. (Reproduced with permission and without alteration
from Kazanjian (1941), Figures 12 and 13)

slowly pulling the mandibular anterior segment forward. Kazanjian additionally

placed two pieces of harvested tibial bone directly over the mental protuberance,
and the other along the left side of the jaw for cosmetic purposes, which ultimately
resulted in an excellent outcome (Fig. 3) (Kazanjian 1941).
Despite the endeavors made by Rosenthal and Kazanjian, distraction osteogen-
esis was yet to gain widespread acceptance and integration into maxillofacial sur-
gery, namely, due to the inadequacy of distraction appliances and the instability of
osseous fixation. A major innovation in mandibular repositioning surgery was con-
ceived and subsequently proven highly versatile with great safety and success
shortly thereafter – Trauner and Obwegeser introduced the sagittal split osteotomy,
which is considered an indispensable tool in the correction of dentofacial abnor-
malities to this very day (Cope et al. 1999; Monson 2013).

3  ilestones and Advancements in Maxillofacial

M
Distraction Osteogenesis

As was illustrated in detail in the previous section, premature versions of distraction

osteogenesis were made by pioneering surgeons, such as Rosenthal and Kazanjian.
The first report demonstrating the application of Ilizarov’s principles to the
358 D. Stanbouly and M. Perrino

mandible appeared in 1973, when Snyder deliberately excised a unilateral 15-mm

bone segment from the mandibular corpus of a dog to simulate a crossbite.
Subsequently, he performed an osteotomy on the shortened mandible and placed an
extraoral distraction appliance. After a 7-day latency period, the device was acti-
vated at a rate of 1 mm per day for 14 days; at the end of which, the original occlusal
relationship was successfully achieved. Additionally, the mandibular cortex and
medullary canal across the distraction gap were seen after 6 weeks of fixation (con-
solidation), during which callus maturation and mineralization transpire. Indeed,
this was the first application of maxillofacial distraction osteogenesis in a “modern
manner” (Cope et al. 1999; Erverdi and Motro 2015).
In 1989, McCarthy was the first surgeon to clinically apply the technique of
extraoral osteodistraction on a human mandible, specifically for children with con-
genital craniofacial anomalies. In the series, he managed to lengthen the mandibles
around 18–24 mm. It was this milestone that propelled the technique of maxillofa-
cial distraction osteogenesis in popularity, as an alternative reconstruction technique
for the correction of craniofacial deformities (Erverdi and Motro 2015).
Despite these initial reports of success in distraction osteogenesis of the human
craniofacial skeleton, the extraoral devices utilized were merely capable of unidi-
rectional (horizontal or vertical) mandibular lengthening only. While the unidirec-
tional vectors generated from the earlier devices were capable of completely
correcting mandibular deficiencies located either exclusively in the ramus or the
body, they were limited in correcting deficiencies that simultaneously involved mul-
tiple regions of the mandible, as is witnessed in congenital syndromes involving
mandibular microsomia or micrognathia. It was thought that the restoration of the
mandible in such complicated cases can be more effectively addressed using inde-
pendent distraction in two directions (Cope et al. 1999).
Molina and Ortiz-Monasterio were the first surgeons to perform bidirectional
osteodistraction in the mandible. They generated two distraction sites via double-­
level corticotomies, one horizontal in the ramus and the other vertical one in the
corpus, allowing them to lengthen both parts of the mandible simultaneously. They
performed their procedure on 87 patients with unilateral hemifacial microsomia and
19 patients with bilateral mandibular hypoplasia, characteristic of Robin sequence
and Treacher Collins syndrome. They managed to achieve a mean elongation of
19 mm in the unilateral group and a mean elongation of 7.5 mm vertically and
14 mm horizontally in the bilateral group. They reported successful improvement in
the facial asymmetry in all patients (Molina and Ortiz-Monasterio 1995).
Multidirectional extraoral distraction appliances were eventually developed,
which enabled manipulation of bone segments in multiple planes of space. Unlike
bidirectional distraction appliances, they were capable of correcting severe man-
dibular deformities in three-dimensional space. Despite the fruitful results brought
about by extraoral distraction devices, they come with two major shortcomings: (1)
their bulky structure can cause considerable social inconvenience, and (2) their
application can lead to permanent facial scars (Cope et al. 1999). These shortcom-
ings instigated the development of intraoral appliances. In 1990, Guerrero was the
first surgeon to report the use of intraoral mandibular appliances in the distraction
Distraction Osteogenesis 359

osteogenesis for 11 patients with transverse (horizontal) deficiencies of the mandi-

ble. Other designs of the intraoral mandibular appliance were subsequently con-
structed with improved form and function by McCarthy and Wangerin. The major
advantages of intraoral appliances include their inconspicuous nature and the lack
of facial scars, exactly countering the disadvantages associated with extraoral
appliances.

4 Considerations in Distraction Osteogenesis

There are three phases in the process of distraction osteogenesis which allows for
the successful application of this technique to the osteotomized bone. The phases,
in order, are latency, activation (or distraction), and consolidation. The latency
phase is the time from the completion of the surgical osteotomy gap to the begin-
ning of the lengthening, or separation, of the bone units. The activation phase, oth-
erwise known as distraction, is the period in which the bone is actively separated
with the goal to increase its dimension in the desired vector(s). During this phase,
immature bone is formed between the bony segments. Consolidation refers to the
period of time after the activation is complete, when the immature bone remodels
into mature, stable, woven bone, thus creating a single bone unit with the desired
increase in dimension.
In order for successful distraction osteogenesis to occur, the phases of treatment
must be carefully timed to occur within the physiologic limits of bone regeneration.
The newly formed bone is a result of membranous ossification of the regenerate, as
there is no cartilaginous intermediate (Saunders and Lee 2008; Gabrick and Runyan
2017). In the early phase of healing, the tissue’s response to ischemia and traction
are critical factors in angiogenesis and osteoinduction of the newly repaired/form-
ing tissues. It is this sequence of signals that attract mesenchymal stem cells and
promotes the proper milieux for bone induction and formation. Though the specifics
are beyond the scope of this discussion, it is these interactions between pro-­
inflammatory cytokines, neo-vascularization and angiogenic factors, transforming
growth factor beta superfamily factors including the bone morphogenic proteins
(BMPs), and the mechanical stresses placed on the regenerate that promotes bone
formation and healing (Saunders and Lee 2008; Gabrick and Runyan 2017).
The latency phase begins after the osteotomy is completed. It is crucial that
enough time elapses for the initiation of callus formation across the osteotomy gap,
as in typical bone and fracture repair. More specifically, if the latency phase is too
short, then there will be insufficient osteoid regenerate deposited between the
actively distracted segments, and hence, the result will be a fibrous or non-union of
the segments. In contrast, if the latency phase is too long, then consolidation of the
segments can occur resulting in inability to actively distract or lengthen the seg-
ments or device failure. There is some debate regarding the ideal timing of the
latency phase, but it is generally accepted to be between 0 and 7 days. The ideal
timing depends upon age, site, blood supply, and any factor that could compromise
360 D. Stanbouly and M. Perrino

healing such as radiation, etc. A younger patient requires a shorter latency period for
DO. For example, a newborn with Robin sequence undergoing mandibular distrac-
tion osteogenesis may have a latency period of 0–2 days versus a teenager with cleft
lip and palate undergoing a maxillary LeFort I distraction osteogenesis who may
have a latency period of 5–7 days – depending on the surgeon’s preference, experi-
ence, and patient-specific clinical factors.
The activation phase begins with the purposeful lengthening of the osteotomy
gap. Ilizarov described the tenets of successful distraction as being device stability,
a latency period, a gradual distraction period, and a sufficient consolidation period
(Ilizarov 1988, 1989a, b). Upon completion of the osteotomy, some form of length-
ening device, a distractor device, must be fixated to the bone segments. Distraction
devices come in many forms including external devices and internal devices, as
discussed previously. Though the external devices are bulky and compromise social
acceptability, patient comfort, and esthetics – they are more able to manage multiple
vectors with the current readily available technology. However, they can be more
difficult to manage precise movements. The common internal distractor device typi-
cally consists of two foot plates, one each for the proximal and distal bony segment,
connected to a rod and screw system that allows the separation of the foot plates as
the screw is turned or activated. Each revolution of the screw will lengthen the
device in a pre-determined amount, i.e., 0.5 mm per turn. In this way a precise and
reliable movement can be obtained eliminating sources of error in the distraction
process. Moreover, ratchet systems have been included to the devices to prevent the
device from accidentally being manipulated in either direction.
Another concept that Ilizarov introduced was osteotomy with minimal periosteal
stripping. The integrity of the periosteum post-osteotomy and application of the
stable distractor device allowed for callus formation and an envelope in which the
conditions are adequate for lengthening of the regenerate. And because of the grad-
ual lengthening, the surrounding soft tissues including the nerve, muscle, endothe-
lium, etc. are believed to lengthen as well – similar to the effects of a tissue expander.
However, debate exists as to the extent of this process and its limitations.
The concept of the rate and rhythm of distraction is also integral to the success of
DO. The rate refers to the amount of lengthening per activation of the device,
whereas the rhythm refers to the frequency of activation. This is also dependent
upon patient-specific factors such as age, site, etc. Again, the pediatric population
can be distracted at an increase rate as compared to teenagers or adults. It is com-
mon for neonates, infants, and toddlers to undergo distraction to a total of 2 mm per
day, with two activations (of 1 mm) occurring daily. In contrast, a teenager or adult
undergoing a LeFort I distraction may only undergo a total of 1 mm per day, with
0.5 mm activations occurring twice daily. If the distraction is too rapid, a non-union
may result, and if it is too slow, then early consolidation will occur. Surgeon-specific
protocols for the rate and rhythm of distraction exist, as a lack of consensus remains
as to the optimal protocol. However, complication rates remain low with the afore-
mentioned guidelines (Hollier et al. 2006).
Consolidation is the next phase and is the period during which the osteoid regen-
erate develops into mature, stable bone. This is again an age-dependent process.
Distraction Osteogenesis 361

Ilizarov initially described consolidation as a minimal period of 6 weeks or when

cortical outlines of the regenerate are visible on radiography. In general, the younger
patient will experience consolidation more rapidly. Additional factors include the
size of the bone and the length of distraction. Therefore, a small alveolar defect will
require less time for consolidation than a 2-cm segment in the body of the mandible.
Adults will typically require 3–6 months of consolidation in which the distractor
device will act as the fixation device and must remain stable throughout this time. It
is this author’s experience that infants and neonates can tolerate a 2- to 3-month
consolidation period, and older children, teenagers, and adults require a minimum
of 3 months. Upon completion of consolidation, the distractor devices are removed.
Therefore, it is critical that stable bone healing has occurred.

5  odern Clinical Implications of Maxillofacial

M
Distraction Osteogenesis

The use of distraction osteogenesis in maxillofacial surgery has increased tremen-

dously over the previous generation, particularly to buttress the maxillofacial skel-
eton in conditions associated with bone deficiency. Distraction osteogenesis is
indicated in deficiency of the maxilla or midface, deficiency of the mandible, and
deficiency of the alveolar bone prior to implant placement (Rachmiel and Shilo
2015). Each surgical technique that is available will have certain instances when it
will be the preferred or optimal method for obtaining the desired result. Distraction
osteogenesis is no exception. At one point, there was a suggestion that distraction
was superior and would eliminate the need for traditional orthognathic procedures.
However, with time it became clear that though DO has specific indications in
which it can provide a superior result to traditional osteotomies and reconstructions,
there are limitations.
DO requires that the patient undergoes multiple surgeries including the osteot-
omy and placement of the distractor device(s), as well as removal of the device(s).
The device itself, whether internal or external, is a space-occupying mass which can
alter facial form and/or cause discomfort due to the bulk – and will stay in place
through the consolidation period. In addition, the device will have a component that
will exit and/or be visible through the skin of the neck, face, cranium, or mouth –
which is the site where the activation rod is accessed for lengthening or distracting
the bone. This provides a point of entry to the underlying tissues with a resulting
increased risk of infection. The exit site can also be a source of discomfort.
Furthermore, DO is an active process which requires twice-daily activation of the
device, which separates the bony segments, and causes a variable amount of dis-
comfort over the period of distraction. This requires a high degree of patient compli-
ance and specifically with pediatric patient’s behavioral management can be
intensive or prohibitive.
362 D. Stanbouly and M. Perrino

Craniomaxillofacial DO typically occurs with some form of computer simula-

tion and virtual planning after either CT or cone beam CT scan of the facial skele-
ton. This provides a significant benefit to limit complications by identifying the
optimal sites for screw and plate placement with bone density evaluation, ability to
avoid vital structures with the osteotomy and screw placement, and vector of dis-
traction for ideal final position of the distracted segment based on the patient-­
specific morphological defect or condition. This same benefit also exists with
computer simulation for traditional surgical procedures. Moreover, as stated earlier,
DO can achieve greater lengths of advancement with a lower risk of relapse, as well
as eliminate large areas of dead space in large advancements with the gradual move-
ment and no need for bone grafting. However, when considering distraction of den-
tate segments of the facial skeleton, achieving an ideal dental occlusion is not
predictable and can result in additional orthognathic procedures to finalize treat-
ment. In contrast, traditional orthognathic surgery can be performed in a one-stage
operation with a predictable occlusal result. Selection of the appropriate treatment,
i.e., distraction versus one-stage reconstruction, should be patient specific with the
goal being the most predictable result.
DO is optimally performed with the use of computer simulation and virtual sur-
gical planning. As stated earlier, this allows for minimizing damage to important
structures while planning for the optimal vectors. Custom surgical guides can be
fabricated, and ideal positioning of the distraction device and management of the
position and size of the screw fixation will be optimized. In addition, given the suc-
cess of MDO for Robin sequence, multiple choices of devices are available which
can be selected to best fit the individual. Moreover, custom devices will likely be a
reality in the near future.

6 Mandibular Distraction Osteogenesis

The primary benefit of distraction osteogenesis is to increase the dimension or

length of the selected bone in the desired vector – either for large movements which
are less stable or impossible for one-stage reconstructions or for its ability to expand
the soft tissue envelope in a gradual manner to decrease dead space or for its effects
on the nerve, endothelium, skin and mucosa, and muscle. A primary indication for
mandibular distraction osteogenesis (MDO) occurs in individuals born with Robin
sequence. Robin sequence is the triad in which a small mandible will lead to glos-
soptosis and then airway obstruction. Because the retropositioning of the mandible
prevents tongue descent from between the palatal shelves, these individuals may
have a cleft palate. Neonates or infants who suffer from Robin sequence may require
assistance with maintaining a patent airway or with feeding, and the severity pres-
ents within a wide spectrum. There are standard algorithms for managing these
newborns which includes conservative management with prone positioning, place-
ment of airway devices such as a nasopharyngeal tube, the use of supplemental
oxygen devices like CPAP, or tongue-lip adhesion.
Distraction Osteogenesis 363

Other indications of MDO include hemifacial microsomia (HFM) and Treacher

Collins syndrome. It is crucial to note that bilateral mandibular deficiency that char-
acterizes the aforementioned indications can decrease the volume of the pharyngeal
airway, potentially resulting in obstructive sleep apnea (OSA) and even tracheos-
tomy dependency (Rachmiel et al. 2005). Mandibular distraction osteogenesis with
either an internal or external device following the appropriate osteotomies is indi-
cated for the aforementioned forms of mandibular deficiency (Rachmiel and
Shilo 2015).
Severe obstruction, refractory to conservative measures, may require invasive
treatment such as intubation, mandibular distraction (MDO), or even tracheostomy
until normal growth relieves obstruction. Severe obstruction, refractory to conserva-
tive measures, may require invasive treatment such as intubation, mandibular dis-
traction, or even tracheostomy. MDO is proven to be a safe and effective means of
predictably relieving upper airway obstruction by creating space for the airway by
advancing the tongue base by lengthening the body of the mandible (Breik et al.
2016; Denny et al. 2001; Sidman et al. 2001). There are risk of complications, which
include damage to developing tooth buds, injury to the inferior alveolar nerve,
injury to the facial nerve, infection, need for additional airway interventions or
repeat distraction, and potential growth restriction (Hong et al. 2012; Paes
et al. 2016).
Mandibular distraction in an older population including toddlers and young chil-
dren presents similar anatomical challenges not only due to the developing struc-
tures including the dentition but also due to the behavioral management and
compliance required for successful treatment. Individuals with distinct craniofacial
anomalies, such as Treacher Collins syndrome, may have a deficiency of not only
the length of the mandible but also the vertical height of the ramus and an obtuse
gonial angle. Vertical distraction of the ramus and condyle remains controversial
due to the potential for ankylosis and predictable surgical outcomes.

7 Maxillary and Upper Midface Distraction Osteogenesis

A primary indication for maxillary DO is for large advancements of the maxilla

when performing a LeFort I osteotomy. This is more common for individuals born
with cleft lip and palate and the resulting restricted anterior-posterior maxillary
growth with a Class III malocclusion. Segmental maxillary distraction, or mobiliz-
ing a discrete segment of the maxilla, is indicated in the cleft patient with large
alveolar defects and has been shown to be successful in closing or reducing the size
of the alveolar cleft. In addition, syndromic patients with midface hypoplasia, such
as those with Crouzon or Apert, etc., may also benefit from a large advancement
with DO at the LeFort I level. In addition, these syndromic persons with significant
midface hypoplasia may extend to the LeFort 2 or LeFort 3 level – and DO can be
the preferred modality for managing the advancement of the upper midface after the
appropriate osteotomy is completed. It is important to remember that the execution
364 D. Stanbouly and M. Perrino

of these procedures is more difficult in patients with abnormal anatomy and previ-
ous surgeries. Relapse of the desired movement can occur to a higher degree. In
addition, obtaining the ideal occlusal result may require a second and definitive
reconstruction.
The case of maxillary deficiency is exemplified by an individual born with a cleft
palate who underwent the standard algorithm of care with repair to the palate at the
ideal time. It is accepted that 25–30% of individuals with a repaired cleft palate will
develop a Class III malocclusion that is likely a result of undergoing the initial sur-
gical repair of the cleft palate (Ross 1987).
This can be corrected by a maxillary LeFort 1 osteotomy – however, in certain
patients the anterior-posterior desired movement is too great a distance to accom-
plish with the standard LeFort I procedure. It is in these situations that a LeFort I
osteotomy followed by distraction osteogenesis through an internal or external
device can improve the ability to achieve the greater desired movement. Similarly,
midfacial hypoplasia is a typical feature of syndromic craniosynostosis, such as
Crouzon’s syndrome, and results in sequelae of exophthalmos, upper airway steno-
sis, sleep apnea, central face concavity, and dental malocclusion. While this was
previously treated through a LeFort 3 osteotomy and subsequent bone grafts to fill
the induced bone cuts, distraction osteogenesis following LeFort 3 osteotomy has
increased in utility over the recent years. One advantage DO holds over bone grafts
is that it is minimally invasive, without the risk of donor site morbidity (Sakamoto
et al. 2020).
More recently, the monobloc operation, which consists of advancement of both
orbits and the midface in one piece, plus advancement and reshaping of the frontal
area, when used in conjunction with distraction osteogenesis has reduced morbidity
significantly (Fig. 4). A large retro-frontal space result after acute expansion when
the monobloc operation is executed. The subsequent communication between the
nasal cavities and the anterior cranial fossa leads to a high (>30%) infection rate due
to the dead space created by the advancement that manifests as meningitis, epidural
abscess, and/or osteomyelitis of the frontal bones with subsequent bone loss. The
gradual expansion of bone when distraction osteogenesis is added into the equation
eliminates the formation of a large retro-frontal space. Negligible infectious compli-
cations and the evasion of frontal bone loss, meningitis, and epidural abscess have
been reported using an internal distraction system (Kumar and Steinbacher 2014).
The final modern indication for DO that will be discussed is alveolar deficiency
for the purpose of implant placement. Maxillofacial trauma, periodontal disease,
and resection of aggressive large jaw cysts or tumors can all cause a significant
reduction in alveolar bone. As was stated earlier in maxillary and midface DO,
alveolar DO is advantageous for increasing the dimensions of the jaws due to its
minimally invasive nature; there is a decreased need for a bone augmentation sur-
gery with the associated risk of donor site morbidity (Rachmiel and Shilo 2015).
Distraction Osteogenesis 365

Preoperative Anatomy Initial Position Final Position - Distracted 20mm

All measurements are approximate. All measurements are approximate.

Guided Holes Guided Holes

Fig. 4 Virtual surgical planning of distraction osteogenesis

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Craniosynostosis Surgery

Jessica S. Lee and Jason W. Yu

1 Ancient Descriptions of Craniosynostosis

Congenital human deformities, especially of the head and face, have known to be
described as early as the time of antiquity. Homer wrote about the warrior, Thersites,
who, in the Iliad, was described as “…the ugliest man who came before Troy…his
head ran up to a point…there was little hair on top of it…” (Homer 1990) (Fig. 1).
This was one of the earliest descriptions of a man with craniosynostosis, and the
expression tête à la Thersite has been used in French literature as a synonym for
oxycephaly.
Craniofacial deformities, however, have not always been viewed as sequelae of
human malformation; instead, particular head shapes were marks of elitist distinc-
tion or divinity in many ancient cultures across the globe (Gaudier et al. 1967). The
Taoist God of Longevity, Shouxing, exemplifies this distinction, portrayed with an
extremely high cranial vault (Fig. 2). The Japanese, Shinto God of Wisdom,
Fukurokuju, has been depicted with a very high forehead (Fig. 3). These marks of
distinction have also been found in the Americas (Incas, Mayas, Pueblos, Navajos,
and Apaches), Africa (Ethiopians), the Philippines, and France (Montaut and
Stricker 1977). In the French regions of Brittany, Normandy, and Toulouse, the
practice of skull deformation through bandaging continued until the end of the nine-
teenth century (Figs. 4 and 5).

J. S. Lee (*)
Private Practice, Northeast Facial & Oral Surgery Specialists, Florham Park, NJ, USA
e-mail: [email protected]
J. W. Yu
Section of Oral & Maxillofacial Surgery, UCLA School of Dentistry, Los Angeles, CA, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 367

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_20
368 J. S. Lee and J. W. Yu

Fig. 1 Odysseus, Agamemnon and Thersites from the Iliad

2 Early Scientific Descriptions of Craniosynostosis

By the sixteenth century, anatomists began to document the existence of cranial

sutures and broad range of characteristics, including suture patterns and premature
suture fusion in a variety of configurations (Hundt 1501), specific abnormal variet-
ies of sagittal and coronal sutures (Dryander 1537), and descriptions of oxycephaly
and brachycephaly (della Croce 1583; Vesalius 1543).
In the late 1790s, Samuel Thomas von Sömmerring (Fig. 6), a German physi-
cian, was the first to describe abnormal head shapes beyond simple descriptions in
the context of abnormal cranial suture development (von Sömmering 1801). His
descriptions have laid the foundation for our modern understanding of craniosynos-
tosis and, subsequently, the development of non-surgical and surgical interventions
(von Sömmering 1839; Winston 1996).
Several decades later, Adolph Wilhelm Otto, a German anatomist, based on his
studies of human and animal anatomy, proposed that a consequence of premature
suture fusion was a compensatory cranial expansion along another trajectory in the
skull, providing the first explanation of the global cranial abnormalities observed
(Otto 1830).
A landmark study published by German physician Rudolf Virchow (Fig. 7) in
1851 described an aberrant growth pattern in which the premature fusion of cal-
varial bone restricted growth perpendicular to the direction of the involved calvarial
suture and promoted compensatory growth, subsequently named Virchow’s law
(Virchow 1851). He initially described this phenomenon as craniostenosis, describ-
ing a narrow or structured skull; however, he later more appropriately named it
Craniosynostosis Surgery 369

Fig. 2 Shouxing, God of

Longevity

craniosynostosis, indicating suture involvement and encompassing all cranial suture

anomalies (Virchow 1851; Sear 1937). Virchow’s observations and contributions
were crucial in the development of surgical interventions for craniosynostosis, and
subsequent modifications were based directly on his observations and principles
(Mehta et al. 2010).
370 J. S. Lee and J. W. Yu

Fig. 3 Shinto, God of

Wisdom

Fig. 4 Ancient Incan Skull

Craniosynostosis Surgery 371

Fig. 5 Man from Toulouse

Fig. 6 Samuel Thomas

von Sömmerring
(1755–1830)

Virchow’s hypotheses and contributions on craniosynostosis remained the stan-

dard for nearly a century as additional perspectives began to emerge, including the
association of craniostenosis with ophthalmological visual loss (von Graefe 1866)
and craniosynostosis with optic atrophy (Friedenwald 1893).
372 J. S. Lee and J. W. Yu

Fig. 7 Rudolf Virchow

(1821–1902)

Although more frequently non-syndromic and monosutural, by the early 1900s,

craniosynostosis was recognized as a component of more complex, syndromic cra-
niofacial anomalies, most notably by French physician Eugène Charles Apert in
1906 and French neurologist Louis Édouard Octave Crouzon in 1912, after whom
two of the most well-known syndromes are named.
In the mid-twentieth century, American anatomist and dentist Melvin Lionel
Moss (Fig. 8) proposed that the primary site of abnormality was within the cranial
base, which led to the secondary fusion of the cranial sutures (Di Rocco 1995; Moss
1954, 1959). His theory was based on four observations: (1) sutures were often pat-
ent at surgery, even when there was a high degree of preoperative suspicion of suture
fusion and characteristic skull abnormality; (2) characteristic abnormalities at the
cranial base occurred with certain suture patterns; (3) excision of the fused suture
did not always improve the cranial shape; and (4) embryologically and developmen-
tally, skull development occurred after cranial base development.
Moss’ theory fell out of favor, however, as surgical treatment directed at the pre-
maturely fused suture demonstrated reversal of the deformity and cranial base and
facial abnormalities appeared to occur as a result of cranial suture restriction
(Persson et al. 1979; Persing et al. 1991). This suggested that craniofacial anomalies
were primarily due to the fusion of sutures, not the cranial base. Although Moss’
theory on the etiology of craniosynostosis was eventually disproven when it was
shown that the suture itself was the primary site of abnormality in craniosynostosis
Craniosynostosis Surgery 373

Fig. 8 Melvin Lionel

Moss (1923–2006)

as cranial base and facial abnormalities responded when the pathology in the cranial
vault was addressed (Marsh and Vannier 1986), his lasting contribution on the func-
tional matrix theory, which proposed that the primary driving force of deposition of
bone in cranial sutures was growth of the underlying brain, would later become a
part of the basis and justification for the minimally invasive, endoscopic approach
for treating craniosynostosis.

3 Early Descriptions of Surgical Intervention

In August of 1888, American surgeon Levi Cooper Lane performed the first strip
craniectomy at Cooper Medical College in San Francisco when approached by a
mother of a child with sagittal craniosynostosis who pleaded to him, “can you not
unlock my poor child’s brain and let it grow?” He described the removal of the fused
suture with a cross-shaped craniectomy, but due to reported anesthesia complica-
tions, the patient died 14 hours postoperatively (Lane 1892).
374 J. S. Lee and J. W. Yu

It was not until year 1890 when the first successful surgical procedure to correct
craniosynostosis was performed on a 4-year-old girl with a severe psychomotor
deficit in Paris by French surgeon Odilon Marc Lannelongue (Fig. 9) (Lannelongue
1890). He introduced a technique to address sagittal suture synostosis in children,
which involved two parallel strip craniectomies lateral to the midline, with a strip of
left behind to protect the sagittal sinus. The strip craniectomy continued through the
adjacent, unaffected sutures, including the coronal suture anteriorly and the lamb-
doid suture posteriorly (Fig. 10) (Boulos et al. 2004; Venes and Sayers 1976;
Chipault 1894). The main goal of this technique was to alleviate intracranial pres-
sure and decrease mortality but to also correct the abnormal head shape after excis-
ing the fused sutures to allow for physiological growth of the cranial vault (Frassanito
and Di Rocco 2011). With this technique, Lannelongue completed strip craniecto-
mies on 59 patients, navigating through complications including blindness, cogni-
tive and neurological damage, hydrocephalus leading to irreparable brain damage,
and even death of one patient (Alvarez-Garijo et al. 2001; Hunter and Rudd 1976;
McCarthy et al. 1995; Speltz et al. 2004). Lane was successful in his second opera-
tion in 1892.

Fig. 9 Odilon Marc

Lannelongue (1840–1911)
Craniosynostosis Surgery 375

Fig. 10 Early sketches of Lannelongue’s linear craniectomy (Chipault 1894)

Despite the quick adoption of surgical technique and use for the treatment of cra-
niosynostosis, German physician Abraham Jacobi, also known as the father of
American pediatrics, denounced the practice of open strip craniectomies at an
American Academy of Pediatrics meeting after reviewing a series of 33 children sur-
gically treated for presumed craniosynostosis. In his review, he found alarmingly high
postoperative mortality rates, with 15 deaths out of 33 children due to major blood
loss (Jacobi 1894). Harvey Cushing, one of the most influential neurosurgeons of his
time, was also very critical of these early techniques, stating that “the introduction in
1891 of linear craniotomy, which has led to innumerable operations said to have been
followed by an improvement in mentality, is a lamentable instance of the furor ope-
randi running away with surgical judgment” (Cushing 1908). With these criticisms,
surgical correction of craniosynostosis fell out of favor for nearly three decades.

4 The Revival of Surgical Intervention

Additional controversy around the craniotomy technique delayed further develop-

ment in the surgical management of craniosynostosis until the early 1920s when
German surgeon Arndt Mehner described a successful technique involving simple
strip craniectomy, or suturectomy, for complete removal of a fused suture, and the
practice of surgical intervention for craniosynostosis was revived (Maher et al.
2010; Mehner 1921). A few years later, American pediatrician Harold Kniest Faber
and neurosurgeon Edward Bancroft Towne at Stanford University published a case
series, reporting excellent preservation of neurological function with minimal mor-
bidity and mortality (Faber and Towne 1927) and later pioneered the concept of
early and prophylactic linear synostectomy for preservation of neurological func-
tion and improvement of cosmesis (Faber and Towne 1943).
376 J. S. Lee and J. W. Yu

By the 1940s, strip craniectomies and suturectomies to treat craniosynostosis

were once again widely accepted, and the importance of early intervention before
2 months of age resulting in more favorable functional and cosmetic outcomes was
demonstrated (Mehta et al. 2010). A new challenge in the treatment of these chil-
dren, however, emerged when reossification with rapid bridging of artificial sutures
was a common complication observed in older children, which often required mul-
tiple, extensive cranial vault remodeling procedures. The outcomes in these com-
plex patients with mature and delayed fusion led Harvey Cushing to question the
indication of late linear craniectomies in these patients and presented surgeons of
the next generation with major challenges to overcome (Mehta et al. 2010).
By the mid-twentieth century, the focus of surgery research, primarily taking
place at Boston Children’s Hospital, shifted to address the limitations of surgical
intervention for children who presented late in the disease course or children who
underwent surgery but presented with reossification at the synostectomy site.
Donald Darrow Matson and Franc Douglas Ingraham, pediatric neurosurgeons at
Boston Children’s Hospital, reported the use of polyethylene film on the edges of
calvarial bone following strip craniectomy to prevent reossification (Ingraham
et al. 1948). Just 1 year prior, neurosurgeons Donald Ray Simmons and William
Thomas Peyton at the University of Minnesota reported the use of tantalum foil
between the edges of calvarial bone following craniectomy (Fig. 11) (Simmons and
Peyton 1947). Both techniques fell out of favor, however, due to reports of reossi-
fication and infection (Mehta et al. 2010). Frank Anderson and Forrest Johnson,

.0075
tantalum
foil

Fig. 11 Tantalum foil adapted to edges of craniectomy to prevent bridging and new bone forma-
tion (Simmons and Peyton 1947)
Craniosynostosis Surgery 377

American neurosurgeons, described a technique in 1956 whereby Zenker’s solu-

tion was applied to the dura to cauterize the ossifying elements within the menin-
ges and promote suture patency but was found to cause seizures (Anderson and
Johnson 1956).
Matson and Ingraham’s technique of simple craniosynostectomy became a main-
stream surgical technique, replaced strip craniectomies as the treatment of choice in
most pediatric neurosurgery texts, and became one of the most common approaches
during this period (Matson 1969). The craniosynostectomy technique involved
removing a strip of bone measuring 1 cm wide at the site of the fused suture and
extending the craniectomy across the adjacent, normal sutures and excising the peri-
cranium to prevent reossification.
By the mid-1950s, surgery for craniosynostosis became safer with less morbidity
and mortality due to significant advances in anesthesia, blood transfusion, and sur-
gical technique as these procedures were performed at a higher volume at major
medical centers such as Boston Children’s Hospital. American neurosurgeon John
Shillito Jr. and Matson reported only two deaths in a large case series of 519 patients
who underwent surgery, demonstrating a mortality rate of 0.39%, refuting Jacobi’s
observation and results just a few decades ago (Winston 1996; Shillito Jr and Matson
1968). With new reports of safer surgeries for craniosynostosis, the importance of
restoring the form of the natural skull early to allow a proper rate of growth for
normal brain development was emphasized. As a result, the consideration for aes-
thetics and cosmesis as one of the primary indications for surgical intervention
became generally accepted (Shillito Jr and Matson 1968). Although simple cranio-
synostectomy and strip craniectomy demonstrated favorable results in young
infants, these techniques fell short when treating older children with advanced dis-
ease or those who presented with reossification at the site of synostectomy, intro-
ducing a new challenge for the next generation of surgeons.

5 Era of Modern Craniofacial Surgery

The early 1960s to 1990s marked a new era in which the innovation of complex
calvarial vault remodeling was developed to overcome the limitations of simple
craniosynostectomy and strip craniectomy techniques, driven by the need for imme-
diate deformity correction to prevent impending neurological dysfunction in older
children and the need to treat secondary compensatory changes at sites away from
the diseased suture (Mehta et al. 2010).
The foundation of modern craniofacial surgery was established by Paul Louis
Tessier (Fig. 12), a French surgeon, widely regarded as the father of modern cranio-
facial surgery. Tessier is best known for his work on Crouzon and Apert syndrome
craniofacial dysostoses, who, unlike his predecessors, emphasized the importance
of aesthetic outcomes to achieve normality (Ghali et al. 2014). Historically, the
treatment of craniofacial dysostoses was anchored heavily on the correction of
facial deformities. Tessier’s solution for craniofacial dysostoses included the
378 J. S. Lee and J. W. Yu

Fig. 12 Paul Louis Tessier

(1917–2008)

advancement of the forehead of supraorbital rims, which involved creating osteoto-

mies through the entire middle third of the facial skeleton with cuts posterior to the
zygoma and orbits along with interpterygomaxillary disjunction to achieve the most
optimal aesthetic results (Fig. 13) (Marchac and Renier 1980).
During the late 1960s and into the 1970s, Tessier developed a series of principles
and procedures which departed from the limitations of maxillofacial surgery and
revolutionized the field of craniofacial surgery by way of transcranial and subcranial
correction of orbital dystopias (e.g., orbital hypertelorism), correction of craniofa-
cial dysostoses (e.g., Crouzon, Apert, and Treacher Collins syndrome), and the cor-
rection of oro-ocular facial clefts (Ghali et al. 2014). His use of autogenous bone
grafts from the rib, iliac crest, or calvarium to prevent relapse in addition to precise
osteotomies enhanced the durability and decreased relapse of his reconstructive sur-
geries (McKinnon 2011). Tessier also developed a collection of surgical techniques
and instruments to harvest and secure bone grafts to aid in these procedures, many
of which are still in use today by craniofacial surgeons.
Tessier’s work gained widespread recognition and praise when he presented a series
of Crouzon and Apert patients treated with a surgical technique, on which he collabo-
rated with French neurosurgeon Gérard Guiot, through an intracranial, frontal approach
to the upper and midface at the International Congress of Plastic and Reconstructive
Surgery in 1967. His successful results were a culmination of Tessier’s innovation,
Craniosynostosis Surgery 379

Fig. 13 Monobloc
frontofacial advancement
developed by Tessier

extensive study of craniofacial anomalies and syndromes including cadaveric dissec-

tions of the craniofacial skeleton, and multidisciplinary training by and collaboration
with Maurice Virenque (maxillofacial surgery), George Huc (pediatric orthopedics),
Sir Harold Gillies and Sir Archibald McIndoe (otorhinolaryngology and plastic sur-
gery, respectively), Pierre Petit (cleft surgery), Gilbert Sourdille (ophthalmology), and
Gérard Guiot and Jacques Rougerie (neurosurgery) who were regarded as the world’s
leaders in each of these fields during this time (Ghali et al. 2014).
Often considered the founding father of craniofacial surgery, Paul Tessier’s leg-
acy defined the philosophy of the next generation of craniofacial surgeons. Tessier
emphasized the importance of collaboration across multiple disciplines, perhaps
honoring his own experiences and training as a young surgeon, and frequently col-
laborated with physicians and nurses within a multidisciplinary craniofacial team to
treat his patients (Ghali et al. 2014).

6 Advanced Cranial Vault Remodeling

Tessier’s groundbreaking approaches to the craniofacial skeleton were expanded

upon with the development of surgical modifications through the 1970s. French
neurosurgeon Jacque Rougerie included remodeling of the anterior cranial vault
380 J. S. Lee and J. W. Yu

simultaneously with suture release (Rougerie et al. 1972). Canadian neurosurgeons

Harold J. Hoffman and Gerard Mohr described the concept of cranial vault and
orbital reshaping with lateral canthal advancement (Hoffman and Mohr 1976).
Shortly thereafter in 1977, American plastic surgeon Linton A. Whitaker proposed
a technique for anterior cranial vault remodeling where three-fourths of the abnor-
mal orbit was osteotomized and advanced to become the level with the contralateral,
normal orbit with lateral bone grafting between the advanced orbit and temporal
bone secured with wires to maintain the newly advanced position (Whitaker
et al. 1977).
John Anthony Jane, an American neurosurgeon, helped advance the development
of total calvarial remodeling with his discovery that the major cause of global cra-
nial deformity was compensatory overgrowth at adjacent sutures. Jane and his col-
leagues developed the pi (π) procedure, named after the shape of the bone that is
removed, where the sagittal, bilateral, coronal, and lambdoid sutures were first
removed and parietal bones out fractured to increase skull width. The sagittal suture
was then removed and used as a strut to maintain the lateral position of the parietal
bones, and the frontal and occipital bones were then secured to the parietal bones
with adjustments of anterior-posterior dimension and frontal bossing. This tech-
nique allowed the surgeon to address the primary suture fusion and provide immedi-
ate correction of the cranial deformity without the need for helmet therapy
postoperatively (Boulos et al. 2004; Jane et al. 1978, 2005).
Daniel Marchac and Dominique Renier, French plastic surgeon and neurosur-
geon, respectively, published the “floating forehead” technique to manage unilat-
eral or bilateral coronal synostosis, which utilized simultaneous suture release
and cranial vault and orbital reshaping where the orbital bandeau segment was
loosely attached to the remaining orbits (Marchac and Renier 1979). Marchac and
Renier proposed that the growing brain would further advance the “released”
orbits and midface forward and allow for natural correction of midface hypopla-
sia in syndromic patients; however, postoperative evaluation of these patients
concluded that their approach failed to support their theory (Marchac et al. 1988).
Through the 1980s, Renier further developed a technique to address sagittal syn-
ostosis with an “H” pattern, where retrocoronal and prelambdoidal segments
were removed together with central segments over the sagittal suture (Di Rocco
et al. 2012).
Summarizing the surgical outcomes of this era, American neurosurgeon
J. Gordon McComb and his colleagues at Children’s Hospital Los Angeles pub-
lished one of the most significant publications on contemporary surgical manage-
ment of craniosynostosis in pediatrics, describing their 6-year, institutional
experience for 250 patients who underwent surgical treatment of craniosynostosis
with relatively low morbidity and mortality rates (6.8% and 0.8%, respectively)
(Sloan et al. 1997).
Craniosynostosis Surgery 381

6.1 Distraction Osteogenesis

Distraction osteogenesis, a bone-regenerative process aided first by an osteotomy

followed by gradual distraction of the vascularized bone segments with deposition
of new bone within the gap, was first pioneered by Italian surgeon Alessandro
Codivilla and further developed for use in lower extremities by Russian orthopedic
surgeon Gavriil Ilizarov. Distraction osteogenesis was first described with its appli-
cation for mandibular advancement in the management of craniofacial microsomia
by American plastic surgeon Joseph G. McCarthy (Codivilla 2008; Ilizarov et al.
1980; McCarthy et al. 1992). Initially described by McCarthy to improve mandibu-
lar asymmetry in patients with craniofacial microsomia, distraction osteogenesis is
more commonly applied to the craniofacial skeleton to correct severe functional
deficits including upper airway obstruction in neonates born with micrognathia or
in adults with severe obstructive sleep apnea. Its application to the midface has
become the preferred method over the traditional advancement technique in grow-
ing children. Posterior cranial vault distraction is used to delay the need for major
cranial remodeling by reducing high intracranial pressure in patients with syn-
dromic craniosynostosis, until a time that major cranial vault remodeling surgery
can be more safely performed (Fig. 14) (Runyan et al. 2017).

Fig. 14 Distraction osteogenesis of the cranial vault

382 J. S. Lee and J. W. Yu

6.2 Spring-Mediated Cranioplasty (Subsection Under Sect. 6)

The spring-mediated cranioplasty technique, introduced by Swedish surgeon Claes

Lauritzen in 1998, was born out of the idea of attempting the results of the surgery
to continue to work over a period of time after the incision was closed (Lauritzen
et al. 1998, 2008; David 2020). Described as less extensive than the “traditional”
cranioplasty techniques, the spring-mediated cranioplasty uses simple linear crani-
otomies powered by implantable dynamic elements in the form of compressive and/
or expansive stainless steel springs, and, therefore, the reshaping of the skull does
not rely exclusively on the action of residual brain growth when compared to linear
craniectomy techniques alone and does not require cyclic activation of a distractor
(Guimarães-Ferreira et al. 2004). Spring placement is most effective if implanted at
3–6 months of age and limits its applications to children who were diagnosed at an
early age (David 2020).

7 Technological Advances in Craniosynostosis Surgery

In 1968, German surgeon Hans Luhr was the first to introduce the concept of inter-
nal fixation with miniature bone plates and screws in the craniofacial skeleton (Luhr
1968). The use of titanium mini- and microinternal plate and screw fixation evolved
into the preferred form of fixation when stability against motion or when complex
three-dimensional reconstruction of multiple segments of bone was required
(Posnick and Ruiz 2000).
Due to the postoperative complications associated with metallic bone fixation
including infection, exposure of underlying plates and screws leading to skin irrita-
tion, and, more significantly, calvarial growth disturbance and intracranial migra-
tion of hardware, the development of resorbable polymer fixation has led to the
clinical availability of resorbable bone fixation implants since 1996 with application
to the craniofacial skeleton for the pediatric population (Eppley et al. 2004).
Despite this advancement, risks of postoperative complications related to resorb-
able hardware failure still remain. A review of 1883 pediatric cranial vault recon-
struction surgeries reported device failure from plate fractures, requiring reoperation
in the postoperative period (0.3%) and delayed foreign body reactions (0.7%) which
resulted in swelling and/or cyst formation (Sanger et al. 2007). Higher complication
rates of 15.3% (Eppley et al. 2004) to 17% (Pearson et al. 2008) due to resorbable
fixation, including palpable plates and a case in which the resorbable plates were
surgically removed due to erythema, have been reported. The development of
resorbable mini-plates and screws as a form of stable fixation continues to evolve as
a fixation alternative especially for use in growing bones and for immobilization of
onlay bone grafts (Posnick 1994).
The continual advancement in extensive cranial vault remodeling during the mod-
ern era of craniofacial surgery not only addressed normal neurological development
Craniosynostosis Surgery 383

but also achieved excellent aesthetic results even for those patients afflicted with the
most complex, multiple-suture synostosis (Vollmer et al. 1984). These procedures,
however, were associated with significant operative time, lengthier hospital stay,
blood loss frequently requiring transfusion, and postoperative complications, which
were considered limitations to extensive cranial vault remodeling and the driving
force in the development of minimally invasive, endoscopic techniques.
Three-dimensional computerized tomography (CT) was first applied to the eval-
uation of craniofacial anomalies in the 1980s (Karatas and Toy 2014; Hemmy et al.
1983). The evaluation of craniosynostosis is enhanced with 3D CT data, and surgi-
cal planning can be completed virtually before the patient is brought to the operat-
ing room. With the development and advancements in computer-aided design/
manufacturing (CAD-CAM), 3D CT data is used to manufacture stereolithographic
models of the patient’s craniofacial skeleton in addition to osteotomy and position-
ing guides, which are used intraoperatively (Figs. 15 and 16). This allows the sur-
geon to transfer the virtually planned surgery to the operating room with improved
precision and efficiency of even the most complex, cranial vault remodeling proce-
dure (Fig. 17).

8  inimally Invasive and Endoscopy-Assisted

M
Craniosynostosis Surgery

Through the 1990s, David F. Jimenez and Constance M. Barone, American neuro-
surgeon and plastic surgeon, respectively, proposed a novel technique involving a
simple suturectomy via an endoscopic approach (Fig. 18) (Jimenez and Barone
1998; Pattisapu et al. 2010). Their technique was based on three basic principles of
craniosynostosis: (1) greater success with surgery early in life; (2) based on Moss’
functional matrix theory, the rapidly growing brain would cause expansion of the
skull into a normal shape if timely intervention occurred; and (3) they employed an
adjunct cranial vault remodeling helmet first introduced by American plastic sur-
geon, John A. Persing, in 1986 into which the brain would help shape the skull
(Pattisapu et al. 2010; Persing et al. 1986).
Jimenez and Barone initially published a small case series in 1998 consisting of
four patients with sagittal synostosis who underwent early endoscopic strip craniec-
tomy and postoperative cranial molding helmets. They found that when compared
to extensive cranial vault remodeling, their procedures demonstrated minimal blood
loss, shorter operative times, earlier hospital discharge, and excellent function and
cosmetic results (Pattisapu et al. 2010). They subsequently published the results of
their technique in 12 patients who were afflicted with various fused suture patterns
and, later, studies of up to 185 patient case series with various sutures involved,
demonstrating continued, long-term success in the setting of extremely rare postop-
erative complications of infection, dural sinus tears, cerebrospinal fluid leaks or
neurological injury, confirming the safety and efficacy of this approach (Jimenez
and Barone 2000, 2010; Jimenez et al. 2002).
384 J. S. Lee and J. W. Yu

Fig. 15 Virtual surgical planning of anterior cranial vault remodeling for metopic synostosis. An
age-matched skull is used to predict the correct cranial morphology
Craniosynostosis Surgery 385

Fig. 16 Patient-specific CAD/CAM manufactured cranial vault osteotomy and positioning guides
with labeling of each individual calvarial segment
386 J. S. Lee and J. W. Yu

a b

c d

Fig. 17 Intraoperative use of CAD/CAM manufactured osteotomy and positioning guides. (a, b)
Cranial vault cutting template allows for accurate placement of osteotomies and labeling each bone
segment. (c) A positioning guide allows for accurate placement of individual calvarial segments to
achieve normal cranial morphology. The calvarial segments are placed into the internal surface of
the template and secured with resorbable plates. (d) The reconstructed cranial vault is then returned
to the patient’s native cranium and secured with resorbable plates
Craniosynostosis Surgery 387

a b

Fig. 18 An endoscope is used to (a) visualize and release the fused sagittal suture, (b) perform a
craniectomy and create barrel staves, and (c) remove the entire sagittal suture and adjacent cra-
nial bone

9 Conclusion

The contributions of the pioneers in craniosynostosis surgery allow surgeons today

to offer treatment options for their patients that are relatively safe and predictable
with excellent functional and cosmetic outcomes. The historical arc of craniosynos-
tosis surgery, first with the development of strip craniotomies in the 1800s, followed
by more advanced, open cranial vault surgery and then more recently and, ironi-
cally, minimally invasive, endoscopic strip craniectomy, illustrates the creativity,
ingenuity, and perseverance of the generations of surgeons who have dedicated their
work toward improving surgical outcomes for their patients.
388 J. S. Lee and J. W. Yu

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Cleft Lip and Palate Surgery

M. Alejandro Fajardo, Derek J. Tow, Christopher Hughes,

and Charles Castiglione

1 Origins, Anatomy, and Incidence of Clefts

Orofacial clefts (OFCs) are among the most predominant birth defects worldwide.
The prevalence of cleft lip (CL) and cleft palate (CP) varies with ethnicity, popula-
tion, and gender. Clefts occur due to disturbances in various development processes
and can affect the eyes, ears, nose, cheeks, forehead, lips, and palate. There are
approximately 15 different forms of facial clefts that have been observed, most of
which are rare. Among the different ethnicities, Native Americans and Asians have
the highest rates of clefts estimating 2 per 1000 births, Caucasians have a slightly
lower rate at approximately 1 per 1000, and African-derived populations have the
lowest rates at approximately 1 per 2500 (Marazita 2012).
In general, most OFCs are considered nonsyndromic. Nonsyndromic OFCs
account for approximately 70% of CL with or without CP and 50% of CP alone.
Currently, with the aid of genetic technology, many of the genetic variations or
mutations that give rise to syndromic forms of OFCs have been discovered
(Marazita 2012).
During embryogenesis, lip and palate formation begins between 6 and 12 weeks
of gestational age. Several tissues are in place by week 4 during normal develop-
ment: paired maxillary processes, the frontonasal prominence, and paired

M. A. Fajardo
Department of General Surgery, School of Medicine, University of Connecticut,
Farmington, CT, USA
D. J. Tow
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA
C. Hughes · C. Castiglione (*)
Division of Plastic Surgery, Hartford Hospital and Connecticut Children’s Medical Center/
University of Connecticut, Hartford, CT, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 391

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_21
392 M. A. Fajardo et al.

Lip Fetal Development

Frontonasal Prominence

Week
Lateral Nasal Prominence
5 Nasal Pit
Eye
Medial Nasal Prominence
Maxillary Prominence Stomodeum
Mandibular Prominence
Nasolacrimal Groove

Frontonasal Prominence

Week
6 Nasal Pit
Eye
Lateral Nasal Prominence
Medial Nasal Prominence
Maxillary Prominence
Nasolacrimal Groove

Stomodeum

Frontonasal Prominence
Week
8 Lateral Nasal Prominence
Eye
Medial Nasal Prominence
Nasolacrimal Groove
Maxillary Prominence
Mandibular Prominence

Frontonasal Prominence
Week
10
Eye
Lateral Nasal Prominence
Medial Nasal Prominence
Maxillary Prominence Nasolacrimal Groove
Philtrum

Fig. 1 Lip fetal development. Week 5 consists of paired maxillary and mandibular processes,
formed fronto-nasal prominence, and paired medial and lateral nasal processes. Week 6 consists of
medial nasal and maxillary processes that make the upper lip and primary palate. From week 6 to
week 8, bilateral outgrowths from the maxillary processes start to grow down on either side of the
tongue to become the palatal shelves. By week 10 there is culmination of upper lip development
with descending of the medial nasal prominence to become the philtrum

mandibular processes surround the oral cavity (Fig. 1). By week 5 the nasal pits
make up the paired medial and lateral nasal processes. By the end of week 6, the
medial nasal and maxillary processes form the upper lip and primary palate, and by
the end of week 10, lip formation is complete (Fig. 1). Bilateral outgrowths from the
maxillary processes start to grow down on either side of the tongue to become the
palatal shelves during week 6 (Fig. 2). By week 12, the tongue drops down, and the
Cleft Lip and Palate Surgery 393

Palate Fetal Development

External Nares
Upper Lip
Gum
Median Palatal Process
Week
6 Lateral Palatal Shelves

Nasal Septum

Upper Lip External Nares

Gum
Median Palatal Process
Nasal Choanae
Week
Lateral Palatal Shelves Nasal Septum
7

Upper Lip
Gum

Median Palatal Process

Week
9 Margin of Palatal Shelf

Nasal Septum

Upper Lip
Gum

Primary Palate

Incisive Foramen
Week
12
Palatal Raphe

Internal Nares
Uvula

Fig. 2 Palate development. Week 6 consist of bilateral outgrowths from the maxillary processes that
start to grow down on either side of the tongue to become the palatal shelves. Week 7 to week 9
consist of continued growth medially by the lateral palatal shelves that undergo fusion in the midline.
By week 12 the tongue drops down and the palatal shelves go up and combine to create the palate
394 M. A. Fajardo et al.

palatal shelves rotate up and fuse to create the palate (Fig. 2). The palate and lip are
fully formed by 12 weeks. Any disruption in this chain of development can cause an
OFC. Studies on the etiology of OFCs date back thousands of years and continue to
this day. While much of the ancient studies on OFCs revolve around folklore, mod-
ern medicine has advanced our understanding using evidence and science
(Marazita 2007).

2 History, Recognition, and Treatment of Clefts

2.1 Cultural History and Understanding of Clefts

Historically, explanations for congenital deformities were focused on a mixture of

faith, superstition, invention, and charlatanism. Many deformities were considered
to signify the presence of an evil spirit in the child affected, and the affected chil-
dren would be cast out from their homes, drowned, or thrown off mountains. These
events are well documented through various ancient texts on the attitudes toward
orofacial clefts (McDowell and Vistnes 1979).
In ancient Sparta, there is evidence that newborn babies with clefts were drowned
in the Tiber River or thrown off Mount Tagete (McDowell and Vistnes 1979). In The
Republic, Plato suggested that discarding these defective children would be consid-
ered an action to remove evil omens and preserve the race’s goodness. Tord Skoog
cited the terracotta statuette in the Potters’ Quarter of Corinth found in 1969, which
dates from around 700 to 300 BC. The figure portrays a clown in such detail that
secondary defects of the premaxilla and nasal alae clearly demonstrate a complete
cleft lip model (Millard 1976a).
Olaus Magnus, an archbishop in Uppsala Sweden, proclaimed in 1550 that
women may become pregnant by leaping over the heads of a hare and that for this
reason these children have a hare mouth, in which the lip permanently separates the
mouth from the nose. This fallacy persisted until 1889, when John Keating recorded
several congenital abnormalities, including cleft lip, and stated that the mother was
causing abnormalities during her pregnancy (Keating 1889).
Interestingly, there was thought to be a lack of facial clefts in ancient Greece, as
in Hippocratic Corpus, a compendium of medical information of the time, there
was no reference to this deformity. Additionally, no mention of OFCs is found in
other early Greek medical and anatomical scripts from 124 to 690 BC, a span of
over 500 years. This includes writings from famous ancient physicians like
Asclepiades, Galen, Oribasius, Caelius Aurelianus, and Paulus Aegineta
(Bhattacharya et al. 2009).
The first person to suggest an embryological basis for clefts was the sixteenth-­
century Italian surgeon Fabrice ab Aquapendente, also known as “The Father of
Embryology.” He suggested that the upper lip forms in the middle during a late
phase of fetal development. Later, eighteenth-century surgeon Meckel theorized
Cleft Lip and Palate Surgery 395

that clefts were formed by five distinct processes which eventually merge together
to form both the top and bottom lips. The most convincing explanation on the origin
of facial clefting was provided by nineteenth-century French surgeon Philippe-­
Frederick Blandin, who suggested that clefting arose due to the failure of fusion of
the palatal bones, the premaxilla, and the maxilla (Bhattacharya et al. 2009). Another
theory was presented by nineteenth-century anatomist William His, who suggested
that the embryological development of the palate and lips is the result of a fusion of
the five processes. Different types of clefts would form depending on which combi-
nation of those five processes did not fuse (Bhattacharya et al. 2009). This was also
one of the first examples of classifying various types of clefts.

2.2 Evolution of Treatment: Cleft Lip

One of the first documented cases of cleft treatment dates back to 390 BC, China.
The first recorded patient was Wey Young-Chi, an 18-year-old male born in Jen
City. After the operation, Wey Young-Chi was able to join the imperial army to
repress an uprising, eventually becoming the General of the Province of Yee and
later the Governor General of six provinces (Millard 1976a).
Early surgical techniques were rudimentary, and detailed accounts date back to
the late 900s AD. Tenth-century Arab surgeon Albucasis suggested creating a small
cut into the lip, inserting a garlic clove, and leaving it for 15 hours. After the garlic
was removed, a bandage moistened with butter was applied to seal the gaps. The
Saxon surgeons of pre-Norman Britain, known archaically as “leeches”, may very
well have been the first to specifically describe the repair of CL in Europe. This was
documented in the Bald’s Leechbook, at the end of the tenth century (McDowell and
Vistnes 1979). Turkish surgeons from the fifteenth century carried on traditions
from the early descriptions of Albucasis. Cafar ed-Din, a Turkish surgeon of this
era, provided depictions in the first Turkish surgical manuscript of cauterization of
lip fissure, which is believed the same technique used during cleft lip repair (Fig. 3a)
(McDowell and Vistnes 1979).
In the early fourteenth century, Flemish surgeon Yperman named the deformity
sartre moude which roughly translates to “notched lip.” Yperman described both
unilateral and bilateral cleft lips and is likely the first to fully document the descrip-
tion of its surgical repair. He proposed that cleft margins be scarified with a bistouri
(an early scalpel), sutured with a triangular needle dipped in wax, and reinforced
with a long needle passed through the lips to accurately approximate the internal
and external wound edges. The needle was then held in place with a wrap-around
figure-of-8 suture or thread. Yperman was the first to document important aspects of
cleft repair, such as ensuring as little of the lip was cut as possible and minimizing
scarring by using the thinnest sutures and needles available (McDowell and
Vistnes 1979).
Sixteenth-century surgeon Ambroise Paré, a tutor of Pierre Franco and one of the
greatest surgical figures of the renaissance, performed extensive research on the
396 M. A. Fajardo et al.

Fig. 3 (a) Cauterization of Lip Cauterization and Early Suturing Illustrations

lip fissure, technique
believed to be used for
repair of cleft lip. (b) Copy a
of Pare’s original woodcut
suturing techniques.
(Taken from “The Source
Book of Plastic Surgery”
by Frank McDowell)

anatomy of lips and palates as well as advanced suturing techniques. Paré is the first
surgeon to include illustrations of repaired cleft lips in his surgical texts (Fig. 3b).
He described the first example of an operation on a cleft lip and demonstrated
impeccable technique. Paré was largely responsible for the gradual abolition of the
cauterization methods used by the Arabians. In Traite des Hernies, Franco, a pupil
of Pare, carefully refined the correction of unilateral and bilateral cleft lips. He rec-
ommended that the cleft lip edges be cut either with a knife or scissors or adjusted
with a cautery. For double cleft lip, he proposed that superfluous portions of the
premaxilla should be cut away with a bone scissors or saw to allow for better clo-
sure. He stressed that an accurate repair created a discreet scar, a result as he stated,
“particularly desirable when the patient was a female” (McDowell and Vistnes 1979).
The use of adjacent tissue was introduced by Hieronymus Fabricius in the six-
teenth century. He suggested the use of buccal mucosa or gingival tissue in closing
the cleft lip. For wide clefts, he used bandages to bring the edges of the cleft together
Cleft Lip and Palate Surgery 397

which reduced tension at the tissue margins prior to initiating repair. Hendrik van
Roonhuysen, a skillful surgeon from Amsterdam in the seventeenth century, was
one of the first to recommend repairing CL soon after birth. He suggested operating
when the infant was 3–4 months old. However, in 1701, Le Clerc suggested that CL
repair should not be done in children, as the constant crying impairs healing and
therefore prevents reapproximation of the edges (McDowell and Vistnes 1979).
The French were some of the first to describe bilateral cleft lip repairs. Eighteenth-­
century surgeon Georges de la Faye from Paris wrote Observations on Cleft Lip
where he described his first bilateral cleft lip operation. In his text, he describes
removing the premaxilla and then bringing the lateral lip edges into the prolabium
which was then left to hang free under the nasal tip. The lip was then pinned together
with one pin near the nose and the other down the lip. The pins would then be
sutured with silk in a figure-of-8 fashion (Faye 1743).
In the early nineteenth century, Joseph-Francois Malgaigne described repair of
cleft lip with a different technique. He departed from a straight-line closure and
instead created two small flaps to close the defect. In a case report from 1844 of
unilateral cleft lip repair, Malgaigne thought that the whistling deformity was an
inevitable sequel to a straight-line closure due to the linear contracture of a straight
scar (McDowell and Vistnes 1979). In the same year, French surgeon Germanicus
Mirault created an innovative method of circumventing this issue by inserting a
triangular flap from the lateral side in a gap to create a horizontal incision on the
medial side. More than a hundred years later, French surgeon Victor Veau pro-
claimed “Mirault is the genius of cleft lip surgery” (Bhattacharya et al. 2009).
Delicate and precise surgical technique resulting in decreased scar hypertrophy
was discussed by Gustav Simon, a German surgeon who is credited with the pre-
liminary closure of the bilateral cleft lip and whom the term “Simon’s band” is
attributed to (Bhattacharya et al. 2009). The term “Simon’s band” or “Simonart’s
band” or “Simonart’s band” refers to a small cutaneous or mucosal bridge that spans
the lateral and medial components of a cleft lip. Gustav Simon was one of the first
to construct labial bands for retrusion of the premaxilla in preparation for a more
definite repair of bilateral complete cleft lip. This is rarely used now due to advances
in dentofacial orthopedics (Mulliken and Schmidt 2013).
Another modification of cleft lip repair was made by nineteenth-century German
surgeon Werner H. Hagedorn, who proposed using a quadrangular rather than trian-
gular flap for the vertical repair. This change gave distinct benefits, particularly for
bilateral clefts since a quadrangular flap simplified repair and helped correct its
protrusion by exerting pressure on the premaxilla. Later in his career, Hagedorn
operated on two children within a week of their birth and became the first to perform
a bilateral lip repair in one stage (McDowell and Vistnes 1979).
In 1930 Blair and Brown revived the triangular flap repair, but they used a much
larger flap. The triangular flap became the most commonly used technique from
1930 to 1955. In 1938, Victor Veau used a small triangular flap from under the alar
base, fitted into a cut in the columella, a feature of Millard’s later operation. By
1940 LeMesurier revived the Hagedorn quadrangular flap, and for quite some time,
it was popular (Fig. 4). By 1952, Tennison published a method of marking the
398 M. A. Fajardo et al.

Quadrangular Flap (Hagedorn-LeMesurier)

Fig. 4 Quadrangular flap. Quadrangle flap for vertical repair of unilateral cleft defects

Triangular Flap (Tennison-Randall)

Fig. 5 Triangular flap. Involves lengthening of the medial lip segment by making a back-cut into
which a triangular flap on the lateral lip segment is introduced

patient by using a bent wire. In 1959, Randall published a triangular flap method
(Fig. 5) in which he created an opening for the flap on the medial side by making an
incision similar to that used by Hagedorn and LeMesurier (McDowell and
Vistnes 1979).
American surgeon Ralph Millard was introduced to cleft lip repair in 1944 at
Boston Children’s Hospital while assisting Donald MacCollum. Four years later in
England, Millard had the opportunity to perform multiple straight-line lip closures
under the supervision of British surgeon William Holdsworth. Dissatisfied with the
results, Millard started to experiment with a rectangular flap from the cleft side in
Cleft Lip and Palate Surgery 399

an attempt to reproduce a Cupid’s bow. Over the next few years, Millard had the
opportunity to work with prominent surgeons Brown, McDowell, LeMesurier,
Straith, and Gillies to name a few. By 1953, as a Navy volunteer in Korea, Millard
had the opportunity to repair multiple cleft lip deformities using the LeMesurier
method. However, he continued to be dissatisfied with the results and decided to
shift gears by performing his first rotation advancement procedure on a 10-year-old
Korean boy. Millard described the first operation where he took a triangular flap
from high on the lateral side, under the alar base, and inserted it into an incision on
the side of the columella, the first reports of a “rotation advancement flap” (Fig. 6).
In 1955, before returning to the United States, Millard presented his rotational
advancement method to Gillies. While in London, he was able to present his paper
“A Primary Camouflage of the Unilateral Harelip” at the International Congress of
Plastic Surgery. Initially there was skepticism, but others adopted his idea and tech-
nique. By 1961, a survey of American and Canadian plastic surgeons indicated that
the Millard technique was widely accepted and used by about 20% of those sur-
veyed. In the coming years, Millard’s rotation advancement method was widely
used in Japan, especially Korea given its birth as a technique there, India, the United
Kingdom thanks to Gillies, and the United States (Millard 1976a). As described by
McDowell, “the best-known technique for the repair of a unilateral cleft lip is the
rotation advancement repair, pioneered by Ralph Millard” (McDowell and Vistnes
1979). Over time, many surgeons have created their own modifications based on the
rotation advancement flap.
In 1965, surgeon William Manchester from New Zealand stated that treatment
of the complete bilateral cleft lip and palate is the most challenging of plastic sur-
gery procedures. Much like Millard, Manchester was familiar with the techniques

Rotation Advancement Technique

Fig. 6 Rotation advancement flap by Millard. This technique uses an upper lip Z-plasty scar
beneath the columella. Described by Millard as the “cut as you go” technique
400 M. A. Fajardo et al.

of LeMesurier but was not satisfied with the results. In the repair of bilateral cleft
lip, LeMesurier advocated lengthening of the prolabium which caused the cen-
tral and lateral portions of the lip to be too long. Even with modifications of the
technique, Manchester found the central vermillion border to show too little bulk.
He then postulated that the goals moving forward would be to keep the prolabial
mucocutaneous ridge at a natural level, allowing the lateral lip to remain short,
but add bulk to the central border of the vermillion. Key points of Manchester’s
technique involved discarding parts of the mucocutaneous ridge, dissecting the pro-
labial mucosa downward toward the vermillion, and allowing for anterior eversion
of the vermillion border. The mucosal dissection is carried to the mucocutaneous
ridge without dissecting upward from the premaxilla. This allowed for production
of a large surface of the prolabium, allowing flaps of vermillion and mucosa to
be made on each side. The flaps were then joined. The resulting eversion of the
labial mucosa provided bulk to the midline and a pronounced cupid’s bow (Fig. 7)
(Manchester 1965).
American surgeon John Mulliken from Boston also described repair of bilateral
cleft lip to be more challenging compared to that of unilateral cleft lip. In 1985,
Mulliken realized that the residual soft tissue deformities seen with methods of bilat-
eral cleft lip repair could be improved by applying five operative principles: main-
taining symmetry, securing primary muscle union, selecting proper prolabial size
and configuration, forming the median tubercle and mucocutaneous ridge from lat-
eral lip tissue, and constructing the nasal tip and columella by anatomic placement
of the alar cartilages. At that time, the repair was often a two-stage procedure but
over the years progressed to a one-stage surgery (Mulliken 1985). By 1995, Mulliken
refined his technique and invoked two additional concepts: simultaneous nasolabial
repair and columellar modeling from nasal tissue alone (Fig. 8) (Mulliken 1995).
Finally, the timing of surgical repair must be performed at the right time to allow
for maximum healing of the cleft. The timing of cleft lip repair has been and is still

Manchester Straight Line Repair

Fig. 7 Manchester straight line repair. Incision across back of the prolabial mucosa, with mucous
membrane dissected down from the prolabial skin towards the remaining central mucocutaneous
ridge. Flaps are developed from the vermilion of the lateral lip elements
Cleft Lip and Palate Surgery 401

Mulliken Technique

Fig. 8 Mulliken technique for repair of bilateral cleft lip defects. Involves reconstruction of orbi-
cularis oris muscle by advancing bilateral muscle segments

highly debated. Two early voices in this debate in the mid-seventeenth century
include Amsterdam surgeons Hendrik van Roonhuysen and Warwick James Cooke.
They claimed that surgery should be performed as soon as possible, at an age of
only 3 or 4 months, and any younger poses a higher risk of failure. This pacing of
the operation continued into the nineteenth century when it was challenged by
Italian surgeon Andrea Ranzi. He surmised that while it is possible to correct a
simple CL soon after birth, operations for more complicated defects may have to
wait until up to 5 years later (Millard 1976a).
The treatment and surgical repair of CL have evolved dramatically over the cen-
turies, and contributions have been made by many trailblazers. Sophisticated tech-
niques are now available for those with cleft lip, and minor modifications are still
being suggested.

2.3 Evolution of Treatment: Cleft Palate

In the past, cleft palate was believed to be the direct effect of syphilitic infection.
Others believed that cleft palate defects were the result of suppurative and/or
destructive disorders such as scurvy, tuberculosis, severe dental and alveolar
abscesses, or decay. Ideas for correcting this condition did not arise until the six-
teenth century, when French surgeon Jacques Houllier proposed suture reconstruc-
tion for syphilitic palatal perforations. Pierre Franco was also one of the first to
suggest an association between cleft lip and cleft palate, insinuating a congenital
origin for defects of the palate (McDowell and Vistnes 1979). By the seventeenth
402 M. A. Fajardo et al.

century, Fabrice ab Aquapendente became one of the first to postulate that many
newborn infants with cleft palates were unable to suck and frequently died as a
result. In 1757, German physician Christopher Jacob Trew published one of the
earliest illustrations of a bilateral cleft lip and palate. In 1766, there were reports of
a French dentist Le Monnier who successfully operated on a child with a complete
palatal cleft extending from the velum to the incisors. Le Monnier’s technique
involved suturing the edges of the cleft and then allowing the wound healing process
to create a scar that bridged the distance of the cleft. In 1776, Italian anatomist
Bartolomeo Eustachi, known for his description of inner ear anatomy, documented
suture repair for cleft palate. Similarly, his technique involved suture repair of a split
velum (McDowell and Vistnes 1979).
In 1819, French surgeon Philibert Roux is credited for performing a successful
closure of a defect of the soft palate. The patient was John Stephenson, a medical
student, who reported in 1820 in his thesis De Velosynthesi, the successful report of
his own cleft velum. Around the same time, German surgeon Karl Ferdinand von
Graefe reported closure of a soft palate defect. Von Graefe reported applying his
surgical repair technique on four patients; however, only one was fully successful.
The surgical approach used by von Graefe, which was similar to that used by Roux,
consisted of five main steps:

1. Separation of the epidermis from cleft edge, which could be performed in two
ways, mechanically or chemically. The mechanical method involved using a
“chisel,” and the chemical method involved using concentrated hydrochloric
acid or sulfuric acid or using a caustic stick. The main goal of both methods was
to scarify the edges of the cleft.
2. Insertion of sutures, which consisted of using four or five stitches.
3. Closure, which involved threading both ends of each suture through the cylindri-
cal mother screw of the ligature screws.
4. General support and local care, which involved increasing inflammation and
minimizing the production of mucus using clear liquid diets and acidified
mouth washes.
5. Keeping the sutures tight, which involved constant readjustment of the slack of
the sutures.

Numerous modifications of palatal repair followed von Graefe’s original descrip-

tion. In 1826, Johann Friedrich Dieffenbach from Berlin described modifications in
suturing and suture material. He continued to acknowledge the fact that cleft palates
had congenital associations, and he also pointed out in his report that new tech-
niques were needed to close the hard palate which most often failed. Dieffenbach’s
contributions also included the introduction of lateral relaxing incisions, the initial
concept of repair timing based on palate function, and the modified suture materials,
which would become precursors to Veau’s wire suture (McDowell and Vistnes 1979).
By 1827, American surgeon Nathan Smith from Massachusetts and Alexander
Hodgon Stevens from New York became the first to contribute reports of cleft palate
repair in America. Stevens was a successful surgeon who had multiple roles later in
Cleft Lip and Palate Surgery 403

his career including professor of surgery at the College of Physicians of New York
now Columbia University, founder and president of the New York Academy of
Medicine, president of the New York State Medical Society, and president of the
American Medical Association (McDowell and Vistnes 1979).
In 1837, British surgeon Robert Liston was the first to illustrate and describe
lateral relaxing incisions for repair of the velum. Liston was very skilled and was
reported to have other surgical contributions including being the first surgeon to
remove a scapula, designing the Liston splint for thigh dislocations, and being the
first surgeon to use ether as an anesthetic (McDowell and Vistnes 1979).
In 1843, talented surgeon from Boston, J. Mason Warren, discovered that it was
easier to dissect gingiva from the palatine bones than from the nasal mucosa in cleft
palate repair. Warren essentially took Liston’s contribution and improved upon it to
create a more profound extension of the lateral incisions. As a result, Warren was
the first to produce loose and relaxed flaps that reached further midline and allowed
for tension-free closure of the oral mucosal flaps (McDowell and Vistnes 1979).
By 1845 Scottish surgeon William Ferguson realized wider clefts consistently
failed to be fully tension-free despite new techniques like relaxing lateral incisions.
Ferguson proposed division of the main components of the palatal musculature:
levator palatini, the palatopharyngeus, and the tensor palatini tendon to minimize
tension in wide clefts for successful repair (McDowell and Vistnes 1979).
In 1861 Bernhard von Langenbeck from Germany described a different tech-
nique for palatal repair using two bipedicled flaps. This became known as the von
Langenbeck palatoplasty (Fig. 9). For the next couple of decades, multiple attempts
were made by surgeons such as Karl Schoenborn and Theodor Billroth to perform
cleft repair with modifications of the von Langenbeck palatoplasty to improve the
repair and speech results. In 1925, American surgeon George Morris Dorrance from

Von-Langenbeck Palatoplasty

Fig. 9 The Von-Langenbeck palatoplasty involves relaxing lateral incisions with a midline closure
of the defect with creation of mucoperiostial flaps
404 M. A. Fajardo et al.

Pennsylvania introduced a palatal pushback and elongation. He also altered the

structure and direction of the tensor palatini tendon by fracturing the hamulus
(McDowell and Vistnes 1979).
In 1931, German surgeon Victor Veau from Burgundy introduced two innova-
tions: the design of flaps to close the cleft in the hard palate and the direct suture
repair for apposition of velar musculature. Veau designed flaps that were detached
mesially and were vascularized only by the posteriorly situated greater palatine ves-
sels. The design of the flaps was a major departure from the Langenbeck operation
(Marquis 1962). Veau advocated the concept of midline levator palatini muscle
reapproximation and emphasized the importance of an encircling suture to pull the
levator muscles together, side by side (Leow and Lo 2008). This became the precur-
sor to more sophisticated intravelar veloplasty techniques.
In 1937 British plastic surgeons T. Pomfret Kilner and William Wardill further
modified Veau’s technique to what became known as the Veau-Wardill-Kilner or
V-Y pushback palatoplasty (Fig. 10). This modification allowed more flap advance-
ment than the von Langenbeck technique and enabled posterior lengthening of the
palate, thus improving velopharyngeal competence (Millard 1976b).
In 1967 Polish surgeon Janusz Bardach first described the two-flap palatoplasty
with intravelar veloplasty. This technique involved creating mucoperiosteal flaps
from the oral surface, mucosal flaps from the nasal lining, and muscular retroposi-
tioning with intravelar veloplasty (Leow and Lo 2008).
By 1978 American surgeon Leonard T. Furlow from Florida introduced the dou-
ble opposing Z-palatoplasty at the annual meeting of the Southeastern Society of
Plastic Surgeons. This technique involved opposing Z-plasties of the nasal and oral
mucosal lining flaps. One side is a myomucosal flap, and the opposite side is a
mucosa-only flap. This is reversed for the nasal lining, so that the velar muscles are
automatically re- and retropositioned with flap inset. The Furlow repair allows for

Veau-Wardill-Killner “V-Y Pushback” Palatoplasty

Fig. 10 V–Y pushback palatoplasty. Involves lengthening of the posterior palate by a pushback
technique with elevation of muco-periostial flaps
Cleft Lip and Palate Surgery 405

Modified Furlow Double Opposing Z-plasty

Fig. 11 Modified double opposing Z-plasty. This technique involves Furlow’s Z-plasty with the
modification by Randall involving bilateral relaxing incisions

soft palate lengthening, and it breaks up a straight-line scar in order to avoid scar-­
induced palatal shortening (Leow and Lo 2008). During Furlow’s presentation,
Peter Randall who was one of the moderators at the meeting applauded Furlow’s
concepts and later in 1986 presented a series of 106 patients using Furlow’s tech-
nique. Randall employed the use of wide lateral relaxing incisions to maximize
tension-free closure (Fig. 11) (Millard 1976a; Leow and Lo 2008).
Most recently, a poll of cleft surgeons in the United States demonstrated that the
most frequently used techniques were the Furlow palatoplasty and the two-flap pal-
atoplasty with an intravelar veloplasty (Katzel et al. 2009).

3 Classification of Clefts Through the Years

In addition to an evolution of surgical techniques and treatments, there have also

been numerous developments in the classification of clefts. Because clefting occurs
in so many ways, creating a classification system that is both simple and inclusive
has been a challenge.
In 1922, American plastic surgeons John Staige Davis and Harry P. Ritchie
announced that the concept of “harelip” should be abandoned and replaced with the
term congenital cleft of the lip (Millard 1976a; Allori et al. 2017). They were among
the first to support a standard classification system. The team proposed a three-­
group classification system allowing a separate definition of the lip, alveolus, and
palate using the alveolar process as a dividing line (Burt and Byrd 2000). The first
group affecting the lip was termed “prealveolar process clefts” and could be unilat-
eral, bilateral, or median. The second group called “postalveolar process clefts”
affected the palate and was further subdivided into soft and hard palate clefts. The
406 M. A. Fajardo et al.

third and final group named “alveolar process clefts” was any clefts involving the
alveolar process and, similar to group 1, could be unilateral, bilateral, or median
(Millard 1976a; Allori et al. 2017; Burt and Byrd 2000).
In 1931, Victor Veau published Division Palatine, which described in detail his
approach to evaluation and management of cleft palate. Despite respect for his col-
leagues, Veau was openly critical of prior classification systems, and he developed
his simplified and classic system:

1. Clefts of the soft palate

2. Clefts of the soft and hard palate up to the incisive foramen
3. Clefts of the hard and soft palates extending unilaterally through the alveolus
4. Clefts of both palates extending bilaterally through the alveolus

Another criticism of the Davis and Ritchie classification system was that Veau
thought using the alveolar process as the dividing line between pre- and postalveo-
lar clefts was set arbitrarily. Danish surgeon Poul Fogh-Andersen was one of many
surgeons who considered the incisive foramen rather than alveolar process to be a
better dividing line. In Inheritance of Harelip and Cleft Palate (1942), Fogh-­
Andersen proposed an alternative to the Davis and Ritchie classification that was
composed of four groups: cleft lip, cleft lip with cleft palate, isolated cleft palate,
and rare, atypical clefts (Allori et al. 2017).
Ardent supporters that favored a developmental anatomy-based classification
included surgeons Desmond A. Kernahan of Chicago and Richard B. Stark from
New York. They supported Fogh-Andersen’s classification and added that based on
the most recent understanding of facial embryogenesis at the time, the use of the
incisive foramen was indeed the embryologically sound division line. The reasoning
was that during gestation, the primary palate extends posteriorly with the incisive
foramen as the posterior border. From that primary palate, the central upper lip and
premaxilla are derived. Should failure of this growth happen, it makes sense that
clefting would occur (Millard 1976a).
Detailed knowledge of past cleft palate classifications is important in pushing the
boundaries of contemporary cleft treatment. As newer technologies enhance our
understanding of human embryology and development, they will also improve our
understanding of cleft lip and palate. Perhaps classification systems will be advanced
in ways surgeons like Davis, Ritchie, or Veau would have never imagined.

4 Psychological and Cultural Influence on Clefts

Cleft treatment aims to restore the anatomy as well as auditory, speech, and feeding
functions of children and enable them to improve physiologically and psychologi-
cally. A key component to cleft care is the involvement of a multidisciplinary team
in order to provide a comprehensive approach for children throughout the cleft care
cycle (Baker et al. 2009). This approach allows for patients to receive the best and
Cleft Lip and Palate Surgery 407

most cost-effective results, at the same time allowing professionals such as dentists,
orthodontists, speech therapists, audiologists, geneticists, social workers, and psy-
chologists a chance to work with surgeon colleagues to become well trained in all
aspects of cleft care (Searle et al. 2017).
That is not to say the results of cleft treatment are perfect. Those born with OFCs
have often voiced concerns with respect to fulfillment, alteration to appearance after
previous surgery, and issues not addressed within the cleft treatment pathway.
Interviews of numerous individuals born with CLP reveal that they did not feel in
control of any portion of the decision-making process as child patients. This finding
may be due in part to older patients encountering a more paternalistic framework
that was pervasive in healthcare when they were adolescents or teens. Unfortunately,
younger people overall had not felt that their feelings were adequately considered in
their interviews with wellbeing experts. A subjective inquiry of 52 adults born with
CLP in the United Kingdom found that many participants questioned the value and
necessity of surgical revision. They also felt that treatment decision-making was too
influenced by the opinions of those around them and consequently led to further
distress (Searle et al. 2017).
While there are many studies that have shown a clear association with CLP and
communication difficulties leading to difficulty during school years, there are newer
studies that demonstrate a contrary view. In a cross-sectional study performed in the
United Kingdom on 103 parents of children and young adults with CLP, there were
many negative outcomes including family impact and psychological distress, but
these were less significant than the positive growth and adjustment that resulted
from their child’s condition. The subjects reported higher utilization of social sup-
port and less avoidance when it came to coping strategies. The study was careful to
say that having these experiences did not necessarily mean it was a net positive on
family dynamics but that having these challenges can possibly contribute to devel-
oping effective coping mechanisms for both the patient and those around them
(Baker et al. 2009).
Families and patients affected by CLP can have a range of experiences in life,
and many of these experiences are heavily influenced by numerous factors includ-
ing severity of physical manifestation, interactions with the treatment team, and
cultural coping mechanisms. While it is important to develop new therapeutic
modalities and surgical techniques to help correct physical abnormalities, it is
equally as important to evaluate and help manage social and psychological concerns.

5 The Present and Beyond

Our understanding and treatment of cleft lip and palate has evolved dramatically
over the centuries. Surgeons from all over the world have made great strides to
define and reproduce “normal” anatomy with a variety of techniques that continue
to improve to this day. Techniques have advanced from simple edge-to-edge sutur-
ing to the providing lip length with quadrangular or triangular flaps, to Millard’s
408 M. A. Fajardo et al.

rotation advancement, to functional muscle repair, and to the addition of primary

nasoplasty. This progression of surgical techniques provides a valuable insight into
the origins and future directions of cleft care, with a focus on functional repair while
maintaining cosmesis.
Further, the classification of clefts has steadily become more accurate over the
years to produce an inclusive and descriptive product. Efficient classification sys-
tems not only help medical professionals and scientists understand the different
types of clefts but also help guide treatment plans and surgical options.
There are large psychological and cultural implications to consider when manag-
ing patients with orofacial abnormalities. Even for those with access to care, insecu-
rities associated with poor oral hygiene, communication, and physical attraction can
develop. These problems were often not addressed in the past but have now become
an integral part of treatment protocols. Common problems that can arise in a child’s
life include behavioral issues, bullying, seclusion, and insecurities that may persist
into adulthood. But evidence has shown that despite these adversities, affected fami-
lies and patients are often stronger and more able to develop healthy coping mecha-
nisms that permeate beyond issues related to a physical affliction. It then becomes
the practitioner’s responsibility to approach care with a more holistic approach to
optimize not only the surgical outcome but also the overall quality of life of each
patient.

References

Allori AC, Mulliken JB, Meara JG, Shusterman S, Marcus JR. Classification of cleft lip/palate:
then and now. Cleft Palate-Craniofac J. 2017;54(2):175–88.
Baker SR, Owens J, Stern M, Willmot D. Coping strategies and social support in the family
impact of cleft lip and palate and parents’ adjustment and psychological distress. Cleft Palate-­
Craniofac J. 2009;46(3):229–36.
Bhattacharya S, Khanna V, Kohli R. Cleft lip: the historical perspective. Indian J Plast Surg.
2009;42(Suppl):S4–8.
Burt JD, Byrd HS. Cleft lip: unilateral primary deformities. Plast Reconstr Surg.
2000;105(3):1043–55.
Faye G. Observations on the cleft lip. Mem Acad R Chir. 1743.
Katzel E, Basile P, Koltz P, Marcus J, Girotto J. Current surgical practices in cleft care: cleft palate
repair and postoperative care. Plast Reconsr Surg. 2009;124(3):899–906.
Keating J. Cyclopaedia of the diseases of children, medical, and surgical. Philadelphia:
J.B. Lippincott Publishing; 1889.
Leow A, Lo L. Palatoplasty: evolution and controversies. Chang Gung Med J. 2008;31(4):335–45.
Manchester WM. The repair of bilateral cleft lip and palate. Br J Surg. 1965;52(11):878–82.
Marazita ML. Subclinical features in non-syndromic cleft lip with or without cleft palate (CL/P):
review of the evidence that subepithelial orbicularis oris muscle defects are part of an expanded
phenotype for CL/P*. Orthod Craniofac Res. 2007;10(2):82–7.
Marazita ML. The evolution of human genetic studies of cleft lip and cleft palate. Annu Rev
Genomics Hum Genet. 2012;13(1):263–83.
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McDowell F, Vistnes LM. The source book of plastic surgery. Plast Reconstr Surg. 1979;63(1):117.
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Millard DR. Cleft craft: the evolution of its surgery, vol. 1. Miami: University of Miami Miller
School of Medicine; 1976a.
Millard DR. Cleft craft: the evolution of its surgery, vol. 3. Miami: University of Miami Miller
School of Medicine; 1976b.
Mulliken JB. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg.
1985;75(4):477–87.
Mulliken JB. Bilateral complete cleft lip and nasal deformity: an anthropometric analysis of staged
to synchronous repair. Plast Reconstr Surg. 1995;96(1):9–23; discussion 24–6.
Mulliken JB, Schmidt A-G. Gustav Simon’s band and the evolution of labial adhesion. J Craniofac
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or palate in the UK. Int J Oral Dent Health. 2017;3:42.
Facial Cosmetic Surgery

Keyur Naik, Pasquale G. Tolomeo, and Elie M. Ferneini

1 Introduction

Cosmetic surgery includes procedures that are intended to improve one’s aesthetic
appearance. Aging, asymmetries and congenital and acquired deformities are all
reasons why patients may pursue cosmetic surgery. A person’s self-esteem is fre-
quently tied to their outward appearance. As such, the market for cosmetic proce-
dures has grown dramatically. Facial cosmetic surgery is typically performed by
highly skilled surgeons who frequently participate in advanced cosmetic or aes-
thetic fellowships after residency. Like plastic surgeons and otolaryngologists, oral
and maxillofacial surgeons (OMS) can pursue such training. Oral and maxillofacial
surgery has a long history in facial cosmetic surgery, and OMS have contributed to
the inception and advancement of modern facial cosmetic surgery.
Today’s principles of facial cosmetic surgery are rooted in reconstructive sur-
gery. Sir Harold Gillies, a physician originally from New Zealand, is frequently
credited as a pioneer in the field of plastic surgery and facial cosmetic surgery. In
1882, Gillies travelled from New Zealand to study at Cambridge University and

K. Naik (*)
Department of Oral and Maxillofacial Surgery, New York University Langone Medical
Center/Bellevue Hospital Center, New York, NY, USA
e-mail: [email protected]
P. G. Tolomeo
Tulsa Surgical Arts, Tulsa, OK, USA
E. M. Ferneini
Beau Visage Med Spa and Greater Waterbury OMS, Cheshire, CT, USA
Department of Surgery, Frank H Netter MD School of Medicine, Quinnipiac University,
North Haven, CT, USA
Division of Oral and Maxillofacial Surgery, University of Connecticut, Farmington, CT, USA

© The Author(s), under exclusive license to Springer Nature 411

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_22
412 K. Naik et al.

subsequently to train in otolaryngology at St. Bartholomew’s Hospital in London,

England (Thomas et al. 2019). At the time, plastic surgery was not an established
specialty, and facial cosmetic surgery was not widely practised. During World War
I (WWI), Gillies performed reconstructive surgery on soldiers with significant facial
injuries. Gillies focused on improving not only on the reconstructive aspect of max-
illofacial surgery but also the cosmetic outcome of his patients, which he noted was
frequently ignored by other surgeons of his time. His work culminated in a seminal
book in the field of plastic surgery titled Plastic Surgery of the Face (1920).
Oral and maxillofacial surgeons have performed facial cosmetic surgery since
its inception. A French oral surgeon, Dr. Hippolyte Morestin, created a centre for
facial reconstruction in Paris and worked alongside Sir Harold Gillies during
WWI (Benmoussa et al. 2017). Facial cosmetic surgery has remained a part of
oral and maxillofacial surgery since that time. However, facial cosmetic surgery
has seen a particular explosion in demand over the past 30 years. As popularity
has grown, surgeons from a variety of specialties have begun to incorporate cos-
metic procedures into their practices. Oral surgeons have done similarly. The
average number of facial cosmetic procedures performed by oral surgery residents
has steadily grown as having the number of post-graduate cosmetic fellowship
opportunities available to oral surgeons. Facial cosmetic surgery looks to be a
rapidly expanding subspecialty within oral and maxillofacial surgery for years
to come.
This chapter will explore the premodern and modern history of specific facial
cosmetic procedures by citing the literature. It will also explore the advancements
in surgical techniques up to the present day. The procedures discussed here are by
no means the total sum of facial cosmetic surgeries performed by OMS. Rather, it is
a discussion of those most frequently preformed. For the purposes of this chapter,
surgeries that fall under the larger umbrella of reconstructive, cleft palate or lip, and
orthognathic surgery will not be discussed as they are covered elsewhere.
Additionally, minimally invasive cosmetic surgery will be discussed in the follow-
ing chapter.

2 Rhinoplasty

Rhinoplasty represents one of the most frequently performed facial cosmetic proce-
dures. According to the American Society of Plastic Surgeons (ASPS), approxi-
mately 220,000 rhinoplasties are performed annually (Plastic Surgery Statistics
n.d.). Rhinoplasty is performed to address cosmetic deformities of the external
nose. While rhinoplasty is referred to as a single procedure, the nasal complex is a
composite structure, and an intricate understanding of its parts is necessary to obtain
the desired result during rhinoplasty. Additionally, the procedure can be combined
with septoplasty in order to improve nasal airflow. Two principal techniques of rhi-
noplasty exist today: open and closed. The open approach is typically taken when a
more comprehensive procedure is required such as combined septorhinoplasty or
Facial Cosmetic Surgery 413

placement of grafts for nasal reconstruction. However, closed rhinoplasty remains

an option for those patients requiring only minor modification.
The first known recordings of cosmetic nasal surgery were in the Ebers Papyrus
written by the Egyptians around 1550 BC. Rhinectomy was a common form of
punishment for a variety of crimes in ancient Egypt. Attempts to reconstruct the
nose after such mutilation became the first written description of nasal surgery
(Whitaker et al. 2007). Rhinoplasty was also documented in ancient Sanskrit texts
written on palm leaf named the Sushruta Samhita, which dates to 1000 BC. A phy-
sician named Sushruta is credited as the author of the text, though parts of the origi-
nal manuscript have been found throughout India, Nepal, China and Tibet likely
signifying a range of contributors. The Sushruta Samhita describes a rotational flap
from the cheek as a method for reconstruction of traumatic deformities to the nose.
Additionally, it describes instrumentation required to perform this early form of
rhinoplasty (Singh 2017).
Modern rhinoplasty was first described in the early to mid-1800s. The term rhi-
noplasty was first coined by German surgeon Karl von Graefe in 1818 in his book
titled Rhinoplastik (Graefe and Hecker 1818). In the text, von Graefe described
innovative forms of nasal surgery, including reconstruction of the nose using a free
flap from the patient’s forearm. However, the surgeon credited as the father of aes-
thetic rhinoplasty has been debated in the literature. In 1887, an American otolaryn-
gologist, John Orlando Roe, developed intranasal approaches for correction of the
nasal tip (Roe 1989). Roe described certain deformities of the nasal tip as a ‘pug
nose’ and developed a closed approach to correct it. In his first publication, Roe was
able to demonstrate his post-operative outcomes through illustrations. In 1891, Roe
published a second article titled The Correction of Angular Deformities of the Nose
by a Submucous Operation, which included endonasal approaches to the dorsal
hump and management of saddle nose deformities as well as pre- and post-operative
photographs of his patients (Fig. 1) (Roe 1981). Others credit Jacques Joseph, a
German orthopaedic surgeon, as the father of modern rhinoplasty. In 1898, Joseph
pioneered rhinoplasty using external incisions and presented his technique as a case
report to the Berlin Medical Society (Bhattacharya 2008). Included in this case
report was a unique theory for the time. Joseph stated that aesthetic surgery can bet-
ter the psychological health of his patients. This theory was considered radical by
his fellow physicians who viewed medicine as a curative practice for physical ail-
ments. In 1931, Joseph published a book of surgical techniques, entitled Rhinoplasty
and Other Facial Plastic Surgeries (Joseph 1931). A number of prominent American
surgeons travelled to Germany to learn Joseph’s techniques and brought rhinoplasty
to the United States by the mid-1900s. Two American surgeons, Irving Goldman
and Maurice Cottle, became leaders of rhinoplasty in the United States. Goldman
became the first president of the American Academy of Facial Plastic and
Reconstructive Surgery (AAFPRS) in 1964, while Cottle established the American
Rhinologic Society in 1954 (Stucker 2003).
The nasal surgery pioneered by Roe and Joseph is termed ‘reduction rhinoplasty’
and was performed with a closed approach. Endonasal rhinoplasty remained the
standard approach until the early 1970s. A Croatian surgeon, Ivo Padovan,
414 K. Naik et al.

Fig. 1 Dorsal hump

reduction. (Courtesy of Dr.
Angel Cuzalina)

presented an external approach to rhinoplasty performed on a series of 400 patients

at the first meeting of the AAFPRS (American Academy of Facial Plastic and
Reconstructive Surgery 1972). The technique was quickly adopted by American
surgeons, namely, Wilfred Goodman and Jack Gunter. In 1978, Goodman published
a paper in the Canadian Journal of Otolaryngology entitled Technique of external
rhinoplasty, which described advancements that he had made to Padovan’s methods
(Fig. 2) (Goodman 1973). In 1987, Gunter presented a secondary rhinoplasty via an
open approach in his article External Approach for Secondary Rhinoplasty (Gunter
and Rohrich 1987). Additionally, the ‘reduction-only’ methods that were demon-
strated by Joseph were replaced by techniques that included both reduction and
grafting. In 1978, Jack Sheen, a plastic surgeon from the University of California at
Los Angeles, published a text Aesthetic Rhinoplasty which included techniques that
advocated preservation of nasal cartilage and its use to shape other aspects of the
nose (Sheen and Sheen 1978). The open approach and ‘preservation’ techniques are
based on the work of these surgeons and their contemporaries. Advances in rhino-
plasty have continued throughout the early twenty-first century. As a greater under-
standing of nasal anatomy is appreciated, the transition from a reductive to a
structural approach remains the driving ideology behind rhinoplasty today. The
greater understanding of nasal anatomy and multiple approaches to rhinoplasty now
allows for individualized treatment for each patient. The cosmetic surgeon must
understand that the nose is the centrepiece of the face and must focus on improving
one’s surgical skill in addition to one’s knowledge. The nose is a framework that
involves various skin types, cartilaginous and bony infrastructures. Each patient
must be addressed individually being that one nose is unlike the other; a standard-
ized treatment plan for all patients will result in a sub-aesthetic outcome.
Facial Cosmetic Surgery 415

Fig. 2 Open rhinoplasty.

(Courtesy of Dr. Angelo
Cuzalina)

3 Forehead and Browlifting

The upper facial third contributes to the youthful and aesthetic face as well as non-­
verbal communication. As such, forehead or browlifting has become an increas-
ingly requested procedures, primarily by older female patients. Typical candidates
for browlifts are patients between the ages of 40 and 65. Ptosis of the brows pro-
gresses as we age. The purpose of a browlift is to reverse drooping and to produce a
more youthful appearance to the upper facial third. As gravity affects the forehead
and brow, the lateral canthal lines, or crow’s feet, and upper eyelid dermatochalasia,
or baggy upper eyelids, become more pronounced. The inclination may be to pursue
eyelid surgery, but brow ptosis may be the true culprit. The surgeon must be able to
identify the true cause of disruption to the upper eyelid complex and address the
issue, i.e. lateral hooding may present as excessive tissue of the upper eyelids. A
number of browlift techniques exist, both open and endoscopic. In this section, we
will discuss the history of open approaches to browlifting.
Forehead and browlifting have been described in the medical literature for over
100 years. The first description was published by French surgeon, Raymond Passot,
in 1919 in an article titled La chirurgie esthetique des ridges du visage (which
roughly translates to ‘Aesthetic surgery of face wrinkles’) (Fig. 3). In the article,
Passot describes the elliptical excisions anterior to the hairline and lateral to the eye
416 K. Naik et al.

Fig. 3 Brow-/forehead lift in combination with rhinoplasty and lower blepharoplasty. (Courtesy
of Dr. Angelo Cuzalina)

in order to lift the forehead and decrease crow’s feet (Passot 1919). Passot’s tech-
nique was followed by that of H. Lyons Hunt who proposed coronal excisions
within the hair-bearing scalp in his 1926 book Plastic Surgery for the Head, Face
and Neck (Hunt 1926). A number of surgeons followed the work of Passot and Hunt
in the 1930s. Advancements in technique included undermining of the pericranium
and resection of the corrugators as described by Fomon in 1939 (Fomon 1939).
Others recommended rhytidectomy in conjunction with the previously described
techniques.
Despite early advances, the procedure remained largely unchanged for the fol-
lowing 20 years. In the 1950s, the browlift techniques previously described were
derided in the literature due to the inability to maintain long-lasting change. New
approaches involved modifications to the frontalis. Chemical destruction of the tem-
poral branch of the facial nerve was attempted to decrease innervation to the fronta-
lis, but a number of unfavourable side effects were encountered including brow
ptosis (Marino and Gandolfo 1964). In 1964, Marino and Gandolfo introduced the
pretrichial incision design which remains popular for open browlifts to this day. In
1965, Vinas proposed excision of a strip of the deep aponeurosis-muscle layer
formed by the frontalis, extending out to the lateral brow. Vinas differentiated wrin-
kles that appear during action from those that are permanent. He determined that
correcting permanent wrinkles would require dermal abrasion and could not be cor-
rected by browlifting alone. He also showed that elevation of the lateral brow was
necessary to accomplish a long-lasting correction (Vinas 1965). In 1972, Regnault
published the first description of the ‘biplanar’ approach to the temporal region as a
way of performing traction on crow’s feet. She advocated a subgaleal dissection to
the eyebrows and upper margin of the crow’s feet with relaxing incisions in the
galea for traction (Regnault 1972). The work of Vinas was further developed by a
Facial Cosmetic Surgery 417

surgeon named Kaye in 1977. While Kaye added to the surgical techniques of the
time, he also contributed to the understanding of forehead aging and the necessary
preoperative exam required for improved surgical planning. Kaye recognized that
sagging upper eyelid skin may not be reversed by blepharoplasty alone. The correct
treatment for many patients may in fact be browlifting. In order to determine the
need for forehead lifting, Kaye recommended elevating the forehead and eyebrows
preoperatively and assessing the effect on eyelid ptosis. By doing so, a surgeon can
more accurately determine which procedure is more appropriate for a patient (Kaye
1977). This assessment is now a routine in the workup of patients presenting with
eyelid ptosis. In 1991, Flowers published an article entitled Periorbital Aesthetic
Surgery for Men: Eyelid and Related Structures (Flowers 1991). In the article, he
further develops the ideas of Kaye and describes the importance of proper brow
positioning prior to blepharoplasty. Since the early 1990s, the approach to the brow-
lift has remained largely unchanged. The introduction of endoscopic forehead lift-
ing has provided surgeons with minimally invasive ways of achieving the results
requested by patients. Despite this advancement, open browlifting remains a main-
stay of treatment.

4 Facelift

Like other cosmetic surgery procedures, facelift has become increasingly popular.
While browlift was intended to reverse the signs of aging of the upper face, the goal
of facelift is to rejuvenate the lower face and neck. The term ‘facelift’ does not
describe one but a number of procedures that can be used to enhance the appearance
of the lower face, including neck lifts liquid facelifts, nonsurgical lifts via radiofre-
quency and plasma energy, minitucks as well as thread lifts. This group of proce-
dures aims to address gradually increasing skin laxity and changes in the
subcutaneous soft tissues of the face and neck. With aging, there is a loss of elastic-
ity and decreased skin thickness along with the development of wrinkles.
Preoperative evaluation of the skin remains one of the most important aspects of
facelift treatment planning. The surgeon can not only determine the type and extent
of procedure required but also advise the patient on the potential for relapse based
on dermal thickness. Correction of the changes to the subcutaneous soft tissues is
equally important. Laxity of the platysma and superficial musculoaponeurotic sys-
tem (SMAS) accentuates the nasolabial folds, facial wrinkles, jowls and the appear-
ance of a droopy chin. An understanding of the changes in the superficial and deep
fat planes of the face is also crucial for sculpting the lower face during a lift. With
age, the superficial plane increases in total volume, while the deep layer descends
and atrophies. Adjusting the superficial fat plane sometimes with adjunctive proce-
dures helps maximize the cosmetic outcome of a facelift. As technology has pro-
gressed, a number of nonsurgical modalities have been developed in an attempt to
achieve similar results. Despite that, facelift surgery remains a cornerstone of facial
cosmetic surgery. This section will explore the development of the procedure and
418 K. Naik et al.

how an increasing understanding of the multiple layers of the lower face and neck
has influenced facelift surgery over the years.
Tord Skoog, a Swedish plastic surgeon, is commonly credited as the pioneer of
modern facelift surgery. Prior to Skoog’s demonstration of a deeper dissection to
manipulate the appearance of the face, a number of surgeons described elevation
and excision of the skin alone or skin and underlying superficial fat. These types of
lifts were first described in the 1920s and 1930s by Dutch and German surgeons.
However, the effects of such facelifts were limited in their ability to produce any
long-lasting change. Only including the skin and subcutaneous fat without involv-
ing the underlying muscle caused significant tension on the skin, which resulted in
frequent and rapid relapse. In 1974, Skoog described a thick cervicofacial flap
developed by raising the skin, the subcutaneous fat and the SMAS together (Skoog
1974). By repositioning these planes in a superior and posterior direction, he was
able to produce reliable tightening of the lower face and neck. While the flap was
robust, dissection occurred in a dangerous plane with a great risk for facial nerve
injury. Additionally, the tissues could only move in one plane, resulting in limited
improvement particularly in the anterior face. As a greater understanding of the
subcutaneous layers of the face and neck was developed and described in the litera-
ture, facelift became a more nuanced procedure. Mitz and Peyronie were the first to
describe the SMAS in Plastic and Reconstructive Surgery in 1976 (Fig. 4) (Mitz

Fig. 4 Facelift. (Courtesy

of Dr. Angelo Cuzalina)
Facial Cosmetic Surgery 419

and Peyronie 1976). Subsequent studies demonstrated how the SMAS serves as an
investing layer of the muscles of the upper lip and a safe dissection plane for avoid-
ing injury to the facial nerve. Surgeons had begun to develop various techniques to
address longevity and obtain even greater results including SMAS plication and
imbrication as well as a combination of platysma transection with medial plication
and lateral pull. Additionally, retaining ligaments were first described by Bosse and
Papillon in 1987 (Bosse and Papillon 1987). These ligaments suspend the SMAS to
the underlying muscle and bone. Laxity of the retaining ligaments results in mid-
cheek grooves and facial jowls. Repositioning of the SMAS can help eliminate
these signs of aging.
In the early 1980s, Owsley, Connell and Aston separately furthered the work of
their predecessors by describing a biplanar or lamellar lift by separating the skin
from the underlying SMAS (Owsley 1983; Connell and Marten 1995; Aston 1983).
While this approach allowed for greater vector control in sculpting of the lower
face, the risks were considerable. Loss of blood supply to the skin or SMAS and
tearing of the SMAS flap were feared complications. In order to avoid these risks,
Hamra furthered the initial technique put forth by Skoog and described the deep
plane facelift in 1990. In an article titled The Deep Plane Rhytidectomy published in
Plastic and Reconstructive Surgery, Hamra demonstrated the composite facelift in
which the orbicularis, malar fat and platysma are raised together with the overlying
skin. In this technique, the SMAS is elevated off the parotid capsule and superficial
to the branches of the facial nerve anteriorly in order to avoid motor nerve damage
(Hamra 1990). In 1995, Ramirez described the subperiosteal approach to the face-
lift. The purpose of this approach was to release the retaining ligaments of the face
and to allow for greater passive repositioning of the soft tissues (Ramirez 1995).
The facelifts described by Owsley, Connell, Aston and Hamra, amongst others,
were significantly more invasive than the early lift proposed by Skoog. However,
over the past 20 years, the development of adjunctive procedures has lessened the
need for extensive facelifts. Fat grafting or lipofilling is the most common proce-
dure done in conjunction with a facelift that addresses facial fat atrophy and allows
for restoration of the facial volume. Approximately 85% of cosmetic surgeons uti-
lize fat grafting to enhance the outcomes of the facelifts they perform (Sinno et al.
2015). The deep medial cheek is a particularly important area to fat graft as signifi-
cant volume is lost in the compartment with aging. By performing lipofilling at the
end of a lift procedure, a surgeon can accentuate the mandibular line angle, restore
malar projection and improve tear trough deformities without more invasive sur-
gery. An equally important adjunct procedure is skin resurfacing. Unlike fat graft-
ing, skin resurfacing procedures are completed at the conclusion of a facelift after
the quality of the skin and flap thickness are visually confirmed. Erbium and CO2
lasers and trichloroacetic acid peel are commonly used, though the utility is limited
to fair-skinned patients (Fitzpatrick I to III) (Wright and Struck 2015). The advent
of new technology has allowed surgeons today to perform less extensive surgery,
leading to shorter operating times and lower rates of serious complications.
420 K. Naik et al.

5 Blepharoplasty

Blepharoplasty encompasses a wide range of surgical procedures performed on the

upper or lower eyelid to improve appearance. Changes in eyelid appearance are
most commonly secondary to aging though environmental factors such as sun dam-
age and aging can also contribute to unaesthetic eyelids. Blepharoplasty focuses on
the removal of excess eyelid skin, modification of herniated fat pads and creation of
a more aesthetic eyelid crease in order to reverse the effects of aging and long-term
environmental exposures. Simply, blepharoplasty can be divided into cosmetic pro-
cedures performed on the upper eyelid and those performed on the lower eyelid. The
indications for surgery differ. Upper eyelid blepharoplasty is typically performed to
improve dermatochalasis, asymmetry and muscle laxity. Certain upper eyelid con-
ditions can be accentuated by brow ptosis. Cosmetic surgeons should evaluate brow
ptosis and counsel on the need for a browlift in order to maximize the results of
upper lid surgery. Lower eyelid blepharoplasty can improve dermatochalasis, ste-
atoblepharon and herniated fat but also ectropion or entropion.
Though the first eyelid surgeries are hard to date, the first recordings of eyelid
diseases can be found in ancient Egyptians’ texts. Dated to 1550 BC, the Ebers
Papyrus describes ectropion, entropion and trichiasis and medical treatments for
each condition (Johnson 2005). The ancient Greeks expanded on the ocular and
periocular diseases described by the Egyptians. The Hippocratic treatises document
cases of eyelid ptosis, blepharitis and epiphora in addition to a litany of other condi-
tions that effect the eye and eyelids. Despite the number of conditions described in
ancient Greek texts, descriptions of surgical correction are limited. It is not until the
development of Roman medicine do surgical procedures of the eyelids become
more commonplace. In 30 AD, Aulus Cornelius Celsus compiled an encyclopaedia
of diseases along with medical and surgical treatments into a text called De Medicina
(Lazzeri et al. 2012). In this textbook, surgical treatments for a number of perior-
bital diseases including eyelid tumours, dacryocystitis and lagophthalmos in addi-
tion to those conditions were previously described by the Greeks. The medical
traditions of the ancient Greeks and Romans were furthered by the Arabs who
invaded the Roman Empire in 600 AD. The early Arabic conquests resulted in an
Islamic Empire that stretched from Central Asia to Northern Africa and present-day
Spain and Portugal. The strong tradition of written text in the Arabic culture resulted
in over 30 textbooks on ophthalmology that were written over the course of the fol-
lowing 500 years. The most notable of these texts named Tadhkirat al-Kahhalin was
written by Ali ibn Isa, a surgeon from Iraq. Isa documented the first upper lid bleph-
aroplasty. In the text, Isa described sustained compression and subsequent necrosis
of excess upper lid skin (Haq and Khatib 2012). Another physician of the time,
Albucasis, wrote about cauterization of excess eyelid skin in order to correct eyelid
ptosis (Al-Benna 2012).
A greater understanding of eyelid anatomy resulted in the modernization of the
procedure by European surgeon in the mid-1800s (Fig. 5). In 1844, Jules Sichel, a
French surgeon, published an article describing the role of herniated orbital fat in
Facial Cosmetic Surgery 421

Fig. 5 Pre- and post-op upper and lower blepharoplasty. (Courtesy of Dr. Angelo Cuzalina)

the appearance of excess upper eyelid skin (Sichel 1844). This idea was furthered
by Ernst Fuchs who demonstrated that laxity of fascial attachments between the
upper eyelid skin and the underlying levator palpebrae resulted in a pronounced
eyelid skin fold. Drawing on his findings, Fuchs described a surgical technique that
not only called for removal of excess upper lid skin but also modification of these
attachments to the levator and tarsus (Fuchs 1896). American surgeon Charles
Conrad Miller made significant contributions by publishing the one of the first text-
books dedicated to facial cosmetic surgery in 1907. In his text titled Cosmetic
Surgery: The Correction of Featural Imperfections, Miller was the first to describe
lower lid blepharoplasty through a subciliary incision (Miller 1907). Another French
surgeon, Julien Bourguet, advanced lower eyelid surgery by describing transcon-
junctival approach to blepharoplasty. He used this approach to remove herniated fat
in order to tighten the lower eyelid (Bourget 1924). These facial cosmetic surgeons
of the nineteenth and early twentieth century laid the groundwork for the subse-
quent advances in eyelid surgery which occurred after World War I.
World War I and II saw an increased need for facial reconstructive surgery, which
led to improved understanding of facial anatomy and rapid advancement of surgical
techniques. Facial cosmetic surgeons, including those who perform blepharoplasty,
drew on the lessons learnt during the two world wars. In 1951, Salvador Castanares
published a comprehensive article describing the orbital fat compartments
(Castanares 1951). He drew on his own work to present novel techniques for treat-
ing herniation of periorbital fat, brow ptosis and lower eyelid bags over the follow-
ing 15 years. Castanares’ methods were largely reductive in nature. He advocated
removal of orbital fat and excess skin in order to make cosmetic enhancements. As
other surgeons have built on his work, there has been shift away from a reductive
approach towards preservation of and addition to the periocular soft tissues. In his
1981 article entitled Fat Pad Sliding and Fat Grafting for Leveling Lid Depressions,
Loeb was one of the first to describe utilizing and repositioning the herniated orbital
422 K. Naik et al.

fat in order to sculpt the periorbital area and soften the tear trough (Loeb 1981).
Like other facial cosmetic surgeries, adjunct procedures have reduced the extent of
surgical correction required during blepharoplasty. In 1997, Coleman described
additive fat grafting to the periorbital areas in order to augment the appearance of
the lower eyelid (Coleman 1997). The advent of new technology and preservative
techniques has shortened surgical time, reduced operative complications and
enhanced patient outcomes.

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Minimally Invasive Cosmetic Procedures

Elizabeth M. Will, Brian M. Will, Michael J. Will, and Alia Koch

1 Introduction

To understand where we are going, it is important to understand where we have

been. For as long as history has been documented, the human race has attempted to
alter appearance through jewelry and costumes, tattooing, and body painting. The
desire for eternal youth is pervasive throughout all cultures. In ancient Egypt,
women would attempt to soften their skin and treat wrinkles by applying ointments
made of mixtures of incense, wax, freshly squeezed olive oil, cypress, and fresh
milk (Parish and Crissey 1988). The word cosmetic originated in the seventeenth
century and comes from the Greek word kosmos which means order or adornment
(Oumeish 2001). Taken literally, cosmetics assist in maintaining order. The order
that most cosmetic patients desire is the restoration of youthful appearance. As we
age, the amount of collagen in our skin’s extracellular matrix decreases, the dermis
and epidermis thin, and there is facial volume loss through lipoatrophy. This results
in skin laxity, wrinkles, and increased skin transparency. These changes are seen in
all humans but affect each individual at varying rates depending on genetic and
environmental factors.

E. M. Will
Department of Obstetrics & Gynecology, New York University Langone Medical Center/
Bellevue Hospital Center, New York, NY, USA
B. M. Will · A. Koch (*)
Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University
Irving Medical Center, New York, NY, USA
e-mail: [email protected]
M. J. Will
Will Surgical Arts, Urbana, MD, USA

© The Author(s), under exclusive license to Springer Nature 425

Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1_23
426 E. M. Will et al.

The emphasis on aesthetics seems to only increase as time passes, and the revo-
lution in cosmeceutical science has reflected that. For the human race, the face is the
focal point in the evaluation of appearance, and the ideals of what constitutes an
aesthetically pleasing facial structure have changed over time. The face constitutes
the foundation for most nonverbal messages including the emotional state of a per-
son, as it is best stated in the ancient proverb, “the face is an index of the mind”
(Kattimani et al. 2019).
The explosion of social media has had an enormous impact on influencing
what we as a society consider beauty. Makeup, air-brushing, and digital engi-
neering have created an almost unattainable ideal of beauty. This has resulted in
an insatiable demand for facial cosmetic procedures to enhance perceived inad-
equacies or to defy the inevitable effects of aging. Many patients are willing to
undergo general anesthesia and surgical cosmetic procedures, but an even greater
patient population elects for regular treatments of minimally invasive cosmetic
therapy. In 2019, there were 18.1 million cosmetic procedures performed in the
United States, 16.3 million of which were minimally invasive (an increase of 2%
from 2018) (American Society of Plastic Surgeons Plastic Surgery Statistics
Report 2019). This chapter will focus on the most popular and frequent in-office
injectable treatments.

2 Needle and Syringe

The use of injectables would not have been possible without the advent of the nee-
dle and syringe as there would be no means of delivering therapeutic substances to
the dermis and subcutaneous soft tissues. The hollow needle was invented by physi-
cian Francis Rynd in Dublin, Ireland, in 1844 (Kravetz 2005). He manufactured the
needle by annealing the edges of a flat strip of steel to make a hollow tube. Rynd
first used the needle to inject sedatives for the treatment of neuralgias (Rynd 1861).
The hypodermic needle and syringe were developed independently in 1853 by
French orthopedic surgeon Charles Pravaz and Scottish physician Alexander Wood.
The first syringe involved a screw-type piston allowing subcutaneous delivery of
small amounts of fluid. Pravaz used the needle and syringe to administer coagulant
to sheep, and Wood used them to inject morphine into humans (Feldmann 2000;
Ellis 2017). Wood generally receives credit for the discovery of the hypodermic
needle as he was the first to use it to deliver medications to humans. Sadly, Pravaz’s
wife died of opioid overdose after self-administration of morphine injections. The
basic functional design of the hypodermic needle and syringe has remained
unchanged since the initial discovery. Advancements such as interchangeable and
disposable plastic parts in the 1950s have resulted in the universal use of these
essential medical devices.
Minimally Invasive Cosmetic Procedures 427

3 Neurotoxins

A chapter on the history of minimally invasive cosmetics would not be complete

without talking about the most popular in-office cosmetic procedure in the United
States, botulinum toxin type A (Botox™) (American Society of Plastic Surgeons
2018). Botox™ is not the only neurotoxin treatment currently available, but it was
the first to be approved by the Food and Drug Administration (FDA) in the United
States and is so commonly used that the word is part of the vernacular of both medi-
cal and non-medical individuals. This neurotoxin offers successful outcomes with a
very limited side effect profile (Jandhyala 2013). In fact, botulinum toxin has such
a low-risk profile that its injections can be used in almost any patient population.
The only absolute contraindications are infection at the site of injection or known
hypersensitivity to a component of the product. Relative contraindications include
pregnancy, breastfeeding, neuromuscular junction disorders (myasthenia gravis or
Lambert-Eaton syndrome), and amyotrophic lateralizing sclerosis (Zhou et al. 2017).
Botulinum toxin is an infamous neurotoxic protein that is the main virulence fac-
tor produced by the bacterium Clostridium botulinum. The toxin is a protease that is
composed of one heavy chain and one light chain (Giordano et al. 2017). It cleaves
the SNAP-25 protein in the presynaptic nerve terminal of the neuromuscular junc-
tion, preventing the fusion and exocytosis of vesicles containing the excitatory neu-
rotransmitter acetylcholine and resulting in a flaccid paralysis (Fig. 1) (Giordano
et al. 2017).
Ingestion of this toxin can cause botulism, with its trademark symptom of
descending flaccid paralysis that begins in the muscles of the face and oropharynx.
Classically, this occurs in adults when they ingest preformed toxin from improperly
canned foods and in infants when they ingest Clostridium spores in honey. Botulinum
toxin is so potent that Lamanna et al. described it as “most poisonous of all poisons”
in their publication in Science in 1959 (Lamanna 1959).
Food-borne botulism has existed for as long as humans have attempted to pre-
serve and store food. Several ancient methods of food storage became a perfect
environment for the growth of Clostridium botulinum and subsequent production of
botulinum toxin. Examples include placing ham in barrels of brine in France, hang-
ing liver sausages from rafters in Austria, and fermenting trout in willow baskets in
Scandinavia (Erbguth 2004). These processes all provide the ideal anaerobic envi-
ronment for Clostridium to thrive and sporulate.
Seven serotypes of botulinum toxin (A, B, C1, D, E, F, and G) produced by dif-
ferent strains of the bacterium have been discovered. Types A and B are the iso-
forms that are capable of causing diseases in humans and are also the serotypes
utilized in medical therapy. It is fascinating to note that the very same neurotoxin
that has the ability to cause fatal disease in both adults and young children can be
purified and used in a wide variety of medical and cosmetic treatments. Botulinum
toxin type A is the most common isoform used in aesthetic clinical practice.
428 E. M. Will et al.

BoNT/B BoNT/D BoNT/C

BoNT/G TeNT

Synaptic cleft
BoNT/F

Syntaxin
Acetylcholine
VAMP/Synaptobrevin

SNAP-25

Synaptic vesicle
BoNT/C BoNT/E
BoNT/A

Fig. 1 Mechanism of action of the various known botulinum toxin subtypes. All forms of botuli-
num toxin interfere with components involved in the exocytosis of ACh at the neuromuscular
junction. Botulinum toxin A is the most well-known, illustrated interfering with the SNAP-25
protein. (GNU head Permission is granted to copy, distribute, and/or modify this document under
the terms of the GNU Free Documentation License, Version 1.2, or any later version published by
the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-
Cover Texts. A copy of the license is included in the section entitled GNU Free Documentation
License. “https://commons.wikimedia.org/wiki/Commons:GNU_Free_Documentation_License,_
version_1.2” (Barr et al. 2005))

Similar to other landmark medical discoveries, botulinum toxin was discovered

by serendipity. Botulism or “sausage poisoning” as it was originally described was
discovered by a small-town German health officer and romantic poet in 1817 named
Justinus Kerner. The study of the toxin was prompted by a 1793 outbreak in Wildbad,
Germany, that originated from locally produced blood sausage (Kerner 1817). The
outbreak involved 13 victims, 6 of whom succumbed to the illness. Before long,
more than 200 cases of the food-borne intoxication were known in this region of
Germany, prompting Kerner to publish the first paper on the disease in 1820 based
on a extensive clinical observation of 76 patients afflicted by what he called “sau-
sage poisoning” (Kerner 1820; Jaspers et al. 2011). In his paper, he describes symp-
toms of mydriasis, diplopia, gastrointestinal upset, and progressive muscle paralysis
Minimally Invasive Cosmetic Procedures 429

(Kerner 1820; Jaspers et al. 2011). Botulism is derived from the word “botulus,”
sausage in Latin (Erbguth 2004; Torrens 1998).
Kerner went on to conduct experiments on animals and himself with botulinum
toxin. He concluded that the toxin worked by interrupting signal transmission in
somatic and autonomic motor systems while sparing sensory systems and mentation
(Kerner 1820; Erbguth 1998). He noted that the toxin forms under anaerobic condi-
tions and possesses lethality at very low doses (Erbguth 2004; Erbguth 1998). These
descriptions of the effects of botulinum toxin earned Kerner recognition as the pio-
neer and father of botulinum toxin therapy.
The discovery of botulism propagated across the globe. In 1895 in Berlin, Emile
van Ermengem, a bacteriologist and student of the infamous Robert Koch, isolated
extract from a raw, partially salted ham that poisoned 34 people attending a funeral
in Ellezelles, Belgium (Devriese 1999). The afflicted experienced symptoms of
mydriasis, dysphagia, dysarthria, and descending muscle paralysis (Erbguth 2004).
Ermengem successfully grew the same bacterium from the ham extract and autopsy
specimens (Van Ermengem 1897; Ting and Freiman 2004). Ermengem also cor-
rectly established that botulism was an intoxication produced by Clostridium botu-
linum, not an infection (Van Ermengem 1897). He noted that the toxin only caused
clinical disease in certain animal species and quickly lost its virulence when heated.
As the canned food industry boomed over the next few decades, botulism became
known in popular culture as a public health hazard. Botulinum toxin was even inves-
tigated as a potential biochemical warfare agent during World War II at Fort Detrick
in Maryland. However, the toxin was never utilized in chemical warfare as it report-
edly could not be aerosolized (Lamanna et al. 1946).
The US government first allowed academic investigation of Clostridium bacte-
rium in the 1940s. The first indication that botulinum toxin may have medicinal uses
was in the field of ophthalmology. Ophthalmologists specializing in eye muscle
disorders were seeking non-surgical injection treatment options for the correction of
strabismus. Various agents were utilized with limited success including local anes-
thetics, alcohols, enzymes, enzyme blockers, and snake venom.
In 1973, the ophthalmologist Alan B. Scott published a paper reporting that
injecting botulinum toxin into the extraocular muscles of monkeys provided long-­
term, non-surgical treatment of strabismus without significant side effects (Scott
et al. 1973). Scott and colleagues developed techniques for freeze-drying and buff-
ering the toxin with albumin while maintaining potency, sterility, and safety and
applied for investigational drug use approval from the US FDA. In 1978, the FDA
granted Scott approval to begin testing small amounts of botulinum toxin type A in
human volunteers. His team injected 56 doses of toxin into 16 patients with strabis-
mus, utilizing an electromyographic needle to record muscle activity and thereby
ensure that the injections were placed into the appropriate extraocular muscle belly.
Scott and colleagues reported that the toxin was able to correct gaze misalignment
without significant local or systemic side effects in his landmark paper, published in
1980 (Scott 1980). Scott trained hundreds of other colleagues to perform these
injections with the novel agent which he called the Latin term for “eye aligner,”
430 E. M. Will et al.

Oculinum™. In 1989, the FDA approved the use of Oculinum™ for the non-­surgical
correction of strabismus, blepharospasm, hemifacial spasm, Meige syndrome, and
the treatment of cervical dystonia and spasmodic torticollis (Walton et al. 1999). In
1989, the pharmaceutical company Allergan purchased Scott’s company and
renamed the toxin Botox™, a name that is synonymous with the toxin today.
In the late 1980s, the oculoplastic surgeon Jean Carruthers in Vancouver, British
Columbia, incidentally discovered the use of botulinum toxin for facial cosmetic
purposes. Jean was first introduced to botulinum toxin type A after spending
3 months with Alan Scott in 1982 as one of the early investigators in the studies that
eventually led to FDA approval of botulinum toxin (Carruthers 2003). Carruthers
began utilizing botulinum toxin type A injections for the treatment of blepharo-
spasm in her patients. In 1987, she reported that injections to the medial brow of a
patient resulted in an “unworried, un-troubled appearance,” first noticed by the
patient’s family (Carruthers 2003). Jean Carruthers shared this observation with her
husband, Alastair Carruthers, an accomplished dermatologist. Alastair experimen-
tally injected isolated botulinum toxin type A into the glabellar regions of his recep-
tionist the very next day. After 2–3 days, he observed that the receptionist’s glabellar
wrinkles had disappeared.
The Carruthers, desiring further characterization of this new use for botulinum
toxin, recruited subjects from their respective practices into a small prospective
study. Jean and Alastair published the first paper reporting the cosmetic appeal of
botulinum toxin in 1992, demonstrating minimized glabellar wrinkles in 18 patients
with intramuscular injections of botulinum toxin A with minimal side effects
(Carruthers and Carruthers 1992). The Carruthers demonstrated that botulinum
toxin was more effective and possessed a favorable side effect profile in the treat-
ment of glabellar wrinkles when compared to other soft tissue augmentation prac-
tices of the time, such as injectable filler and fat grafting (Fig. 1). Of note, the
Carruthers were not the only ones to note the potential use of botulinum toxin in
facial cosmetics. A group at Columbia University observed similar clinical manifes-
tations, but chose not to pursue these findings due to interests in other potential
neurologic uses of botulinum toxin (Blitzer et al. 1993).
The doctors Carruthers had the perfect ingredients to launch a robust botulinum
toxin practice, with Alastair’s dermatologic patient population and Jean’s access to
purified botulinum toxin (Fig. 2). At first, many patients were hesitant to allow
injection of a potentially fatal toxin into their bodies. However, as the doctors
Carruthers conducted additional trials and presented their findings at dermatology
meetings, their practice gained traction. Their treatment of forehead and ocular
wrinkles with botulinum toxin injections became so popular that Jean completed
training in cosmetic surgery and stopped treating ophthalmological patients alto-
gether, and Alastair stopped performing dermatologic cancer surgery, limiting his
practice to head and neck cosmetic procedures.
Since the Carruthers’ landmark paper in 1992, many different formulations of
botulinum toxin have become available and approved for use worldwide. In 2009,
the FDA recommended the use of specific names rather than serotypes when
Minimally Invasive Cosmetic Procedures 431

Fig. 2 Illustrates the effectiveness of botulinum toxin A injections in elimination glabellar wrin-
kles. The image on the left is prior to neurotoxin injection, and the right image was after 25 units
of botulinum toxin A to the glabella. (Picture used with permission. Courtesy of Michael J. Will
MD, DDS, FACS)

referring to the available formulations of botulinum toxin in order to prevent confu-

sion. The formulations available in North America include on abotulinum toxin A,
abobotulinum toxin A, incobotulinum toxin A, and prabotulinum toxin A. There
have been numerous large randomized control trials proving the effectiveness of
various individual formulations of botulinum toxin for the treatment of dynamic
rhytids, glabellar lines, and crow’s feet (Carruthers et al. 2002; Grimes and Shabazz
2009; Carruthers et al. 2006). Few randomized trials have directly compared the
efficacy of the different formulations of botulinum toxin. Studies have suggested,
however, that there is not much difference in overall efficacy of the various formula-
tions, although they differ in onset of action, pain with injection, and duration of
action (Sattler et al. 2010; Flynn 2010).
The popularity of botulinum toxin injections has increased dramatically since its
first use in facial cosmetics. From 2000 to 2008, minimally invasive cosmetic treat-
ment with botulinum toxin increased by 537% to an estimated five million treat-
ments per year (American Society of Plastic Surgeons 2010). Over the same time
period, surgical cosmetic procedures such as facelift and blepharoplasty decreased
by 16% and 32%, respectively (American Society of Plastic Surgeons 2010). In
2019, 7.7 million Botox™ procedures were documented, an increase of 4% from
2018, making it again the most popular minimally invasive cosmetic procedure in
the United States (American Society of Plastic Surgeons Plastic Surgery Statistics
Report 2019). Botulinum toxin is now utilized for multiple facial cosmetic concerns
that can be improved with regional muscle relaxation, including dynamic rhytids on
the upper face and skin lines located on the lower face and neck.
Botulinum toxin is also used to treat a variety of non-cosmetic conditions in the
head and neck region, including oromandibular dystonia, cervical dystonia, tension
headaches, migraine headaches, post-herpetic neuralgia and myofascial temporo-
mandibular dysfunction. Botulinum toxin was first used in oral and maxillofacial
surgery in 1992 when Dr. Alistair Smyth published the remarkable effects it had on
patients with “square jaws” or masseteric hypertrophy (Smyth 1994). In 1999, Dr.
432 E. M. Will et al.

Brian Freund was the first oral surgeon to report the effective use of the toxin in
treatment of TMD with injections into the masseter and temporalis under electro-
myographic (EMG) guidance (Freund and Schwartz 1999). Today, botulinum toxin
is used throughout medicine and dentistry, and its indications for use will likely
continue to broaden.

4 Dermal Fillers

Over the past two decades, most medical and dental practices that offer cosmeceu-
ticals have embraced the art and science of facial fillers. Soft tissue fillers are the
second most common cosmetic procedure performed worldwide after injection of
botulinum toxin (Ballin et al. 2015). In 2019, 2.7 million soft tissue filler procedures
were performed in the United States, a 1% increase from 2018 (American Society
of Plastic Surgeons Plastic Surgery Statistics Report 2019). Middle-aged women
comprise the majority of injectable filler patients, but it is becoming more and more
common for facial cosmetic practices to treat both younger and older patients of
both sexes (American Society of Plastic Surgeons Plastic Surgery Statistics
Report 2019).
As we age, there is decreased thickness and elasticity of the skin, lipoatrophy,
and resorption of the craniofacial skeleton, all of which lead to facial volume loss
(Ballin et al. 2015). It has been long appreciated that facial volume loss is one of the
primary factors contributing to an aged look. Clinical signs of age-related facial
volume loss include decreased facial contours, sagging skin, flatter cheeks, depres-
sion of the oral commissures, and hollowing of the eyes. A 2007 study utilizing
facial dissection of cadavers demonstrated that subcutaneous fat in the face is highly
compartmentalized and changes in the volume and positioning of these compart-
ments contribute to the aging facial appearance (Rohrich and Pessa 2007). The
administration of fillers can be used to restore a semblance of youth by replacing the
lost tissue volume and inducing effacement of overlying skin wrinkles. The cos-
metic applications of dermal filler are vast, including softening of glabellar and
horizontal forehead lines, replacing periorbital fat, elevating the brow, correcting
temporal fossa wasting, adding fullness to the cheeks, decreasing depth of the naso-
labial and nasojugal folds, treating melomental (marionette lines) and oral folds,
and even chin, lip, and mandibular augmentation. Soft tissue fillers can also be used
to correct or repair cosmetic contour defects that are unrelated to the aging process
such as HIV-associated lipoatrophy, atrophic scarring, and acquired or congenital
facial asymmetry secondary to bony or soft tissue abnormalities.
There are over 100 filler products at the disposal of the facial cosmetic practitio-
ner. There are currently five main materials that make up the majority of fillers
available on the market. The available absorbable filler materials are collagen, hyal-
uronic acid, calcium hydroxyapatite, and poly-L-lactic acid. The only non-­
absorbable or permanent material available is composed of polymethylmethacrylate
(PMMA) beads, a popular compound used in ophthalmology and restorative
Minimally Invasive Cosmetic Procedures 433

dentistry. This chapter cannot possibly cover all of the available formulations.
Instead, the discussion will focus on the key historical discoveries and broad catego-
ries of facial fillers that helped shape today’s facial cosmetic rejuvenation
opportunities.
From a historical perspective, it is helpful to be aware of the original filler prod-
ucts, their discovery, and their shortcomings to gain an appreciation and understand-
ing of the fillers available for use today. History has taught us that novel technologies
and agents must be used with extreme caution as serious complications can arise,
sometimes many years after the initial treatment.
The first technique utilized for injectable filler was fat grafting. The first docu-
mented fat grafting procedure occurred in 1893 when the German surgeon Gustav
Neuber filled out facial defects resulting from osteomyelitis scars by transplanting
dermal fat from the upper extremity to the orbital region (Klein 2006). Neuber did
this by performing a lipectomy from the upper arm and transferring the gross har-
vest to the dermis of the atrophic site; however, this technique resulted in significant
resorption over time. In 2020, a similar technique of fat grafting is still being used
by many cosmetic surgeons and was recently repopularized with the advent of
suction-­assisted lipectomy with blunt cannulas for fat harvest.
The first reports of injections of a foreign substance for use as a filler can be
traced back to 1899, when the Austrian surgeon Robert Gersuny injected petrolatum
mineral oil to replace a missing testicle following castration caused by tuberculous
epididymitis (Glicenstein 2007). The immediate success of this treatment encour-
aged Dr. Gersuny to utilize petrolatum as a filler for soft tissue defects. However,
petrolatum has a melting temperature similar to body temperature and became
quickly liquified when injected subcutaneously, and so the search for the material
for an injectable filler continued.
The German chemist Baron Karl Ludwig von Reichenbach discovered paraffin
in 1830 by isolating it through the dry distillation of beech-wood tar (Goldwyn
1980). He observed the substance to be inert and unreactive and aptly named it par-
affin from the Latin word parum (barely) and affinis (affinity). Soon, surgeons
began experimenting with using the material as a cosmetic filler as it had a melting
temperature of 65 degrees Celsius, well above body temperature. However, paraffin
injections were associated with severe secondary late complications including
embolization, migration into the surrounding tissue causing nodules, paraffinomas,
and granuloma formation (Glicenstein 2007; Ridenour and Kontis 2009). By 1901,
literature emerged outlining the potential life-threatening complications of inject-
able paraffin, including a report of a 39-year-old woman who underwent paraffin
injection for urinary incontinence and went on to develop pulmonary and cerebral
emboli (Goldwyn 1980). The most infamous paraffin filler complication causing
disfigurement was seen in the Duchess of Marlborough, Gladys Spencer-Churchill
(Fig. 3). The Duchess underwent paraffin injection in 1901 to the nasal dorsum that
subsequently migrated to her chin, producing paraffinomas throughout her face and
causing severe disfigurement (Ridenour and Kontis 2009). Even with the reports of
these severe and even life-threatening complications, paraffin fillers remained popu-
lar for the first 20 years of the twentieth century. They were used primarily for
434 E. M. Will et al.

Fig. 3 The Duchess of

Marlborough Gladys
Spencer-Churchill
(1881–1977), the second
wife of the ninth Duke of
Marlborough. She was
well-known for her beauty
before undergoing
injections with paraffin
filler complicated by
migratory “paraffinomas”
that caused severe facial
disfigurement “https://
creativecommons.org/
publicdomain/mark/1.0/
deed.en”

cosmetic indications such as filling of face wrinkles, adding volume to the cheeks,
and augmenting nasal defects.
The next foreign body substance utilized as a filler was silicone. Like paraffin,
silicone is an inert, clear, oily substance that can be easily injected. Since its initial
use, there has been debate over its safety. The literature is inundated with examples
of disastrous complications associated with silicone injections, and these cases have
received worldwide media attention. However, proponents of the use of silicone as
an injectable agent assert that the complications can be explained by the use of
impure silicone in improper amounts. Proponents of silicone assert that pure
medical-­grade silicone can be an excellent filler agent when delivered by an experi-
enced provider.
The Swedish chemist Johann Berzelius is credited as the first to isolate elemental
silicon in 1824 (Chasan 2007). Silicone was originally produced in mass quantities
Minimally Invasive Cosmetic Procedures 435

by the Dow Corning Corporation for use in the aerospace, electronics, and defense
industries (Chasan 2007). John Holter, a toolmaker, was the first to bring attention
to the potential of silicone’s medical use. After having a baby affected by hydro-
cephalus, Holter was motivated to develop a silicone-based hydrocephalic shunt
that was placed in the first patient in 1955 (Chasan 2007). In Japan following World
War II, silicone was used for the first time in cosmetics. Silicone was injected into
the breasts and buttocks of prostitutes in an attempt to achieve a more “westernized”
appearance (Chasan 2007). This practice spread to the United States, becoming
especially popular in the entertainment capitals of California and Nevada.
The plastic surgeon James Barrett Brown was among the first to recognize the
potential use of silicone for soft tissue supplementation to the face, publishing his
findings in 1953 (Brown et al. 1953). Simultaneously, JT Scales published a list of
criteria for the ideal soft tissue substitute which included a substance not modified
by soft tissue, chemically inert, lack of inflammation or foreign body reaction, non-
carcinogenic, non-allergic, sterilizable, able to be fabricated in the desired form, and
capable of resisting mechanical strain (Scales 1953). Brown believed silicone would
fit Scales criteria, and although his initial interest was the use of silicone in burn
victims, he reasoned that silicone injections would offer a safe treatment for small
contour deficiencies like scars and wrinkles. However, by the 1960s, Barrett Brown
and others noted that silicone had many complications similar to those seen with
paraffin injectables including migration, fistulation, and even several reported cases
of death. It was particularly concerning that the severe inflammatory complications
could be seen many years after silicone injections.
In 1965, Dow Corning Corporation developed a purified medical-grade silicone
to be tested as an injectable, referred to as MDX4-4011. In a 1977 study, the
Canadian plastic surgeon Theodore Wilkie published a study on the treatment of 92
patients with a total of 230 treatments with MDX 4-4011 over a 10-year period
showing 13 granuloma formations, most occurring in the glabella (Wilkie 1977).
The consensus at that time was that because of this complication, silicone inject-
ables were not safe for use. In 1989, a group of dermatologists reviewed the safety
of silicone and concluded that the previously reported problems with silicone soft
tissue augmentation were associated with impure products, excess volumes, or
inappropriate locations (Swanson 1989). In 2013, a team that included the Carruthers
published a study where they evaluated the safety and efficacy of highly purified
medical-grade 1000-cst liquid injectable silicone to treat HIV-associated facial
lipoatrophy. They utilized the “micro-droplet” technique, whereby small amounts
of silicone were deposited deep into the dermis and subcutaneous tissue over the
course of months. Twenty patients with HIV-associated lipoatrophy were treated
with injectable silicone over the course of a maximum of six sessions with 2.0 cc
injected each session. The results showed that at 18 months, there were no adverse
effects and all patients achieved complete correction of lipoatrophy (Chen et al.
2013). This study suggested that liquid injectable silicone could be safe when used
in the hands of an experienced provider.
The use of injectable silicone for facial cosmetics remains a hotly debated topic
today. The US FDA considers injectable silicone an investigational device and has
436 E. M. Will et al.

yet to approve silicone for widespread cosmetic use. Cosmetic surgeons and emer-
gency rooms throughout the United States continue to see the complications of sili-
cone filler treatments, most performed in other countries with silicone of
unknown purity.
In many ways, the quest for the perfect filler still continues today, although new
innovations are constantly being made. The universally agreed-upon characteristics
of the perfect filler are still in line with Scales criteria from the 1940s with a few
additional desirable features including the following: the volume injected is the
volume of correction, long-lasting, a natural feel and look, inexpensive, and fully
reversible. Currently, there are no fillers on the market that meet all criteria, but
there are many formulations that come close.
Animal collagen-based products were the first to be FDA-approved for use as
cosmetic injectables and laid the foundation for the many filler products that suc-
ceeded it. After several years of study, development, and testing, collagen gained
FDA approval in 1981 (Knapp et al. 1977). The first of these bovine-derived colla-
gen fillers to hit the market were Zyderm™ and Zyplast™. The use of collagen filler
for lip enhancement became popularized in American culture by actress Barbara
Hershey in the 1988 movie Beaches (Klein 2006).
While successful, the bovine collagen fillers did have several notable side effects,
most significantly a foreign body reaction. Bovine collagen requires a sensitivity
test before use to ensure that the patient’s immune system will tolerate the foreign
substance. Classically, patients had to be inoculated with the material in the fore-
arm, and if no local allergic response was seen at 30 days, the material was assumed
safe for further dissemination. Some providers advocated for two consecutive
monthly negative allergy tests prior to cosmetic injections to the face. The need for
allergy testing was a major drawback to its use, as cosmetics patients were reluctant
to wait 30–60 days to achieve their desired effect. Bovine collagen is also associated
with severe swelling at the site of injection, likely due to local immune response to
the foreign material. Furthermore, the bovine collagen products did not have the
long-lasting effects that patients were seeking, lasting only several months. Finally,
outbreaks of avian flu, swine flu, and prion diseases made animal-based collagen
fillers less attractive to patients. Despite these drawbacks, the bovine collagen prod-
uct Bellafill™ remains available on the market and is approved for use as a filler for
nasolabial folds and moderate to severe facial acne scars.
While the bovine collagen products were successful and safe compared to prior
available injectables, there was a demand for a substance that lasted longer and did
not require sensitivity testing prior to injection. This resulted in the development of
hyaluronic acid (HA) products. HA was first discovered in the vitreous humor of
cow’s eyes in 1934 (Meyer and Palmer 1934). It was used overseas as a filler decades
before receiving FDA approval for cosmetic use in the United States in 2003 after
many studies found it to be safe and effective (Duranti et al. 1998). HA is by far the
most popular and commonly used filler today.
HA is a naturally occurring glycosaminoglycan that is found ubiquitously
throughout the extracellular matrix of human connective tissue. It is responsible for
stabilizing intercellular structures, producing a viscoelastic framework for collagen
Minimally Invasive Cosmetic Procedures 437

and elastin to bind. It is extremely hydrophilic, capable of binding 1000 times its
weight in water (Olenius 1998). HA-based filler has a much longer duration of
effect compared to collagen fillers (Narins et al. 2003). The extended longevity of
HA fillers is due in large part to the process of isovolumetric degradation. Collagen
fillers are continually metabolized through phagocytization and degradation,
whereas HA fillers are degraded as water is drawn into the hydrophilic glycosami-
noglycan molecule.
HA is harvested in large quantities for use in filler by two methods: bacterial
fermentation and extraction from rooster combs. The rooster-derived products have
a shorter duration effect compared to their bacterial-derived counterparts (Ridenour
and Kontis 2009). There has been some hesitation from patients to have animal
products injected, prompting innovation of non-animal HA fillers. The first non-­
animal HA filler to receive FDA approval for use in the United States, and credited
for the explosion in popularity of HA fillers, was Restylane™ in 2003 (Fig. 4).
There was an enormous marketing campaign targeting baby boomers associated
with the introduction of Restylane™ in the United States, securing a significant
market share for the product (Niamtu 2011). In 2005, the FDA-approved popular
competitor Juvederm™. Other animal-based HA fillers introduced in the early
2000s include Hyalaform™ and Captique™. However, these products were pro-
duced via the rooster comb technique, received with hesitation by patients, and did
not last long as the non-animal-based HA fillers. For these reasons, the non-animal
options Restylane™ and Juvederm™ have remained the most popular HA fillers
since their introduction.
Since the introduction of the non-animal HA fillers, there have been minor
enhancements to the products. For example, Juvederm Ultra XC™ was released in
2010 and included local anesthetic with the injectable although many clinicians do
not see significant utility in this advancement. The noxious stimulus of the needle
and fluid bolus would have already occurred by the time the local anesthetic took
effect, providing minimal increased comfort during the treatment. However, many

Fig. 4 Illustrates the effectiveness of Restylane™ (HA filler) at treating deep nasolabial folds and
atrophic lips. The image on the left was prior to volume enhancement, and the image on the left
was taken 1 week following Restylane™ injections to the nasolabial fold (2 cc) and upper and
lower lips (1 cc). (Image used with permission, courtesy of Michael J Will MD, DDS, FACS)
438 E. M. Will et al.

patients come in demanding the formulations that have a combined local anesthetic
due to successful marketing campaigns conducted by the filler companies.
While HA products remain most popular, newer technologies such as the inject-
able implant poly-L-lactic acid from the alpha hydroxy acid family have been intro-
duced. Sculptra™ was the first of these products to become FDA approved for the
treatment of HIV-associated facial lipoatrophy in 2004. The poly-L-lactic acid par-
ticles initiate an inflammatory reaction causing local tissue fibroblasts to produce
collagen. Sculptra™ treatments typically require multiple sessions as the full clini-
cal effect of the injections may not be apparent for 1–2 weeks. This product is used
by some clinicians for the off-label filling of lines and wrinkles (Niamtu 2011).
Injectable calcium hydroxyapatite, marketed as Radiesse™, is another new tech-
nology, receiving FDA approval in 2006 for the correction of facial lipoatrophy and
moderate to severe wrinkles (Ridenour and Kontis 2009). Radiesse™ is composed
of 30% calcium hydroxyapatite suspended in a sodium carboxymethylcellulose,
glycerin, and high-purity water gel carrier (Ahn 2007). The calcium hydroxyapatite
microspheres are similar to the inorganic components of bone and teeth. Radiesse™
is injected deep into the subdermal plane, where the gel carrier is degraded over a
period of 1–3 months, and the calcium hydroxyapatite particles serve as a scaffold
for new collagen deposition, inducing local collagen production from fibroblasts.
Radiesse™ filler provides immediate correction, and clinical effect can last
1–2 years (Ahn 2007).
The only permanent filler on the market contains PMMA beads, originally mar-
keted as ArteFill™. ArteFill™ was rebranded in 2014 as Bellafill™, a suspension of
PMMA beads in a bovine collagen delivery vehicle. The PMMA beads are not
absorbed by the body, inducing fibroplasia and becoming encapsulated by endoge-
nous collagen (Ballin et al. 2015). A major drawback to Bellafill™ is that a sensitiv-
ity test is necessary before use to ensure there is no allergy to the bovine collagen.
The major concern with the use of permanent filler is the possibility of late-onset
complications such as migration of the material, as was seen in prior permanent
filler materials like paraffin and silicone (Funt and Pavicic 2013). Despite this con-
cern, Bellafill™ was FDA approved for correction of nasolabial fold in 2006 and the
treatment of acne scars in 2015.

5 Conclusion

The demand for products to fight the effects of facial aging and enhance appearance
will likely continue to increase. History has shown us that the human race has an
insatiable need to alter perceived defects in appearance with cosmeceuticals of vari-
ous kinds. This high demand provides lucrative opportunities for both drug compa-
nies and practitioners and will likely continue to drive the development of new
products and expand the utility of existing products.
Minimally Invasive Cosmetic Procedures 439

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Index

A local anesthesia, 62–66

AAOMS Special Committee on Maxillofacial neuromuscular blockers, 60–62
Oncology and Reconstructive parenteral anesthesia, 57–58, 62–63
Surgery, 273 sedative hypnotics, 59–60
ab Aquapendente, Fabrice, 394 Anna Ladd, 85–86
Accreditation Standards for Clinical Anterior subapical segmental osteotomy, 199
Fellowship Training in Oral and Anterolateral thigh flap, 299
Maxillofacial Surgery, 269 Aristotle (384-322 BCE), 94
Accreditation Standards for Clinical Arthrocentesis, 341–343
Fellowship Training Programs, 270 Asepsis, 45–48, 117
Actinomyces, 116 Association for the Study and Application of
Adolf Neuber, Gustav, 315 the Methods of Ilizarov
Albert, Eduard, 314 (ASAMI), 355
Alveolar deficiency, 364 Axonotmesis, 317
Ambroise Paré, 34, 39–42
American Academy of Ophthalmology and
Oto-laryngology (AAOO), 92 B
American Association of Oral and Babcock, William Wayne, 316
Maxillofacial Surgeons Bacillus dentalis viridans, 116
(AAOMS), 269–274 Bagheri, Shahrokh, 323
American Board of Oral and Maxillofacial Balanced anesthesia, 61
Surgery (ABOMS), 99, 274, 275 Ballin, Max, 201
Anatomists Barber-surgeons, 198
Andreas Vesalius, 15 bloodletting, 31
art and atlases, 22–27 cutting hair, 31
cadaver acquisition for education, 21–22 European Medical Education, 33–34
Claudius Galen, 14, 15 London Barber-Surgeons Guild, 35–37
modern anatomical imaging, 17–20 notable Barber-Surgeons, 34–35
sphenoid bone, 16, 17 origin of, 31, 32
Ancient Egypt, 109 scope of practice, 32–33
Andreas Vesalius, 15 setting bones, 31
Anesthesia, 43–45 tooth removal, 31
inhalation anesthesia, 51–56 BellafillTM, 438
intravenous anesthetics, 59–60 Bilateral mandibular hypoplasia, 358
intubation and inhaled anesthesia, 56–57 Bilateral sagittal split osteotomy, 215

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 443
Springer Nature Switzerland AG 2022
E. M. Ferneini et al. (eds.), The History of Maxillofacial Surgery,
https://doi.org/10.1007/978-3-030-89563-1
444 Index

Bimaxillary advancements, 230 Cosmetic surgery, 101

Bimaxillary alveolar osteotomies, 215 aging, 411
Biomet-Lorenz total joint stock prosthesis, 338 blepharoplasty, 420–422
Bi-scapular free flap, 297 facelift, 417–419
Blepharoplasty, 420–422 forehead and brow lifting, 415–417
Blind procedure, 202 OMS, 411
Bone augmentation, 143–148 principles, 411, 412
Bone grafting, 101 rhinoplasty, 412–414
Botulinum toxin injections, 431 Council on Dental Education of the American
British Anatomy Act, 22 Dental Association, 269
British jaw surgery unit, 78 COVID-19 pandemic, 27
British War Office, 74 Cranial vault remodeling, 379, 380
Bronchopneumonia, 75 distraction osteogenesis, 380, 381
Bunnell, Sterling, 317 spring mediated cranioplasty
Byzantine Compiler, 91 technique, 382
Cranio-mandibular, 163
Cranio-maxillary, 163
C Craniostenosis, 368
Carl-Olof Siggesson Nylén, 317 Craniosynostosis surgery, 369
Carnochan, John Murray, 313 ancient descriptions, 367
Cellulitis, 75 cadaveric dissections, 378–379
Certificate of added qualification (CAQ), 275 cranial vault remodeling, 379, 380
Chamberlain, Jack, 322 distraction osteogenesis, 380, 381
Claudius Galen, 13–15 spring mediated cranioplasty
Cleft lip (CL) technique, 382
classification, 405, 406, 408 early scientific descriptions, 368, 369,
embryogenesis, 391 372, 373
evolution of treatment, 395–401 foundation, 377
history, 394, 395 limitations, 377
nonsyndromic OFC, 391 minimally invasive and endoscopy-­
prevalence, 391 assisted, 383
psychological and cultural principles and procedures, 378
influence, 406–408 recognition and praise, 378
Cleft palate (CP) surgical intervention, 373–377
evolution of treatment, 401–405 technological advances, 382, 383
See also Cleft lip (CL) Crouzon’s syndrome, 364
Closed osteotomy technique, 202 Cruickshank, William, C., 313
Cobalt-chrome (Co-Cr) alloy, 335 Cushing, Harvey, 315
Comminuted mandible fracture, 225
Commission on Dental Accreditation (CODA),
269, 270 D
Committee on Oral, Head and Neck Oncologic da Vinci, Leonardo, 310
and Reconstructive Surgery Davis, Loyal, 317
(COHNORS), 273 Dean Smith, 72
Complex regional pain syndrome (CRPS), 314 Deep circumflex iliac artery (DCIA), 295, 296
Composite operation, 260 Deep inferior epigastric perforator (DIEP)
Compound fractures, 47 flap, 299
Condylar prosthesis, 337 Dellon, A.L., 318, 322
Condylotomy approach, 335 Dental forceps, 127, 129
Cone beam computed tomography Dental implants, 135, 137, 138, 151
(CBCT), 19, 150 Dental pain, 3
Contemporary Karl Storz model, 342 Dentofacial deformities, 230
Corpus Hippocraticus, 394 Dermal fillers, 432–438
Index 445

Desormeaux, Antoine Jean, 339 exodontia and prosthetic dentistry, 74

Dieffenbach, Johann Friedrich, 402 external wounds, 74
Dimitroulis, G., 332 front line triage and stabilization, 72
Disruptive innovation, 263–265 Jane Poueplet, 85–86
Distraction osteogenesis (DO), 229, 230 modern plastic surgery, 73
ASAMI, 355 oral and maxillofacial surgery, 74
biological principles, 354 routine dental care, 74
biological process, 353 shaping dental events, 72
complications, 353 Sir William Kelsey Fry, 82, 83
considerations in, 359–361 soft tissue reconstruction, 76
craniosynostosis surgery, 380, 381 surgeons of sidcup, 81
low-energy subperiosteal corticotomy tertiary care centers, 72
technique, 354 Father of Radiation Protection, 19
maxillary and upper midface DO, 363, 364 Ferguson, William, 403
maxillofacial surgery Fibula free flap, 296, 297
advancements, 357–359 Fogh-Andersen, Poul, 406
clinical implications, 361, 362, 365 Fogh-Andersen’s classification, 406
craniofacial complex, 355, 356 Food and Drug Administration (FDA), 138
development, 355 Forehead and brow lifting, 415–417
limitations, 355 Frozen section technique, 255
orthognathic surgery, 355
“over the face” appliance, 356, 357
MDO, 362, 363 G
Division Palatine, 406 Galen of Pergamon, 309
Doctrine of Hippocrates, 254 Gardner Colton, 53
Donoff, Bruce, 320 Gaspare Tagliacozzi (1545-1599), 100
Dynamic navigation, 150 Gay, Jean, 341
General anesthesia, 58
Genioplasty, 208
E Georg Bartisch (1535-1607, 93
Early mandibular osteotomies, 200, 201, 204 Ghali, G.E., 322
Edwin Smith Papyrus, 89 Gigli saw technique, 203
Egyptian medicine, 89 Global speciality, 222
Egyptian Sekhet, 90 Gluck, Themistocles, 315, 322
Émile Létiévant, John Joseph, 314 Great War, 71
Empyema, 75 Guided bone regeneration (GBR), 148
Epidermal growth factor (EGF), 149 Guild of Barbers, 34
Epker, Bruce, 322 Gunning splint, 181, 182
Esthetic subunits, 282 Guralnick, Walter, 320
European Medical Education, 33–34 Guy du Chaliac, 310
External fixation, 163
Extraoral approach, 204
Extraoral distraction devices, 358 H
Extraoral panoramic radiography, 19 Hammond, W.A., 313
Hausamen, Jarg-Erich, 320
Head and neck surgical specialties
F cleft lip, 89
Facelift, 417–419 immobilization methods, 89
Facial artery musculomucosal flap (FAMM), ophthalmology, 93–94
301, 302 oral and maxillofacial surgery, 94–100
Facial reconstruction otolaryngology, 90–92
Anna Ladd, 85–86 plastic and reconstructive /
Central Power surgeons, 83–85 surgery, 100–103
446 Index

Head, Henry, 315 history, 107, 108

Head/neck tumor surgery islamic medicine, 112, 113
AAOMS, 271–274 medieval Europe, 113, 114
ABOMS, 274 modern understanding, 115–117
antibiosis and anesthesia, 256 Rome, 110–112
certificate of added qualification, 275 Inhalation anesthesia, 51–56
CODA, 269, 270 Insulin-like growth factor (IGF), 149
composite operation, 260 Intensity-modulated radiation therapy
disruptive innovation, 263–265 (IMRT), 246
essential ancillary services, 253–254 Internal fixation, 163
frozen sections, 255 Intraoral mandibular appliances, 358
general surgery training, 265–269 Intubation, 363
histopathology, 255 Isolated anterior maxillary segmental
Journal of Oral and Maxillofacial osteotomies, 213
Surgery, 276 Isolated posterior maxillary segmental
medical documents, 253 osteotomies, 214
microsurgical reconstructive surgery, 276
OMFS/MD residency programs, 265–267
oncologic and reconstructive surgery J
fellowship programs, 270 Jacobus de Voragine, 6
paradigm shift, 257 Jane Poueplet, 85–86
patients, 253–254 Jaw fracture, 179
providers, 253–254 Johannes Esser, 84
The Society of Head and Neck Johann Friedrich Dieffenbach's, 101
Surgeons, 261–263 Joseph Lister, 45–48
Hemifacial microsomia (HFM), 363 Joseph Priestly, 52
Hemostasis, 39–42 Journal of Oral and Maxillofacial Surgery, 276
Herophilus of Chalcedon, 309 Juvenile idiopathic arthritis (JIA), 335
Highet, W Bremner, 319
Hillerup, 322
Hinsikinus, 35 K
Hippocrates (460-270 BCE), 89, 94 Kazanjian’s methods, 76
Hoffmann, Paul, 316 Kiesselbach, John, 322
Hoffman-Pappas device, 338 Kostečka’s condylar neck osteotomy, 206
Holmgren, Gunnar, 317
Horace Wells, 43–45
Hullihen, Simon P., 199, 200 L
Hydroxyapatite (HA), 146 Lafranco of Milan, 310
Lambert, Robert, 320
Le Fort I osteotomy, 211–212, 215, 364
I LeFort III osteotomy, 101
Ilizarov, Gavriil, 354 Leonardo da Vinci, 22, 23
Imperial Crisis (235-284 CE), 4 Levator palatini, 403, 404
Indian method of rhinoplasty, 284 Liston, Robert, 403
Infection Local and regional flaps, 286–290
ancient Egypt, 109 Local anesthesia, 63–66, 75
antibiotic era, 118, 119 London Barber-Surgeons Guild, 35–37
antiquity, 109 Louis XV, 37
asepsis, 118
contemporary evidence-based care, 121
diagnostic x-ray imaging, 119, 120 M
early modern period, 114, 115 Mackenzie, 320
Greece, 109 Mackinnon, Susan, 318, 322
Index 447

Mandibular condyle, 335 recovery pattern of injured nerves, 315

Mandibular distraction osteogenesis (MDO), Seddon’s classification of nerve
362, 363 injuries, 318
Mandibular subapical osteotomies, 207, 208 stepwise approach, 312
Mandibular trauma hellenic Tinel-Hoffmann Sign, 316
18th century, 179, 180 tingling sign, 314
19th century, 180–183 trigeminal neuralgia, 313
compression osteosynthesis, 187, 188 Wallerian degeneration, 318
early medieval period, 178 Microsurgical reconstructive surgery, 276
early-mid 20th Century, 183–186 Microvascular surgery, 291
Hellenic period, 178 Microvascular surgery,
middle ages, 179 foundation of, 292–294
miniplate osteosynthesis, 189–191 Midface hypoplasia, 363
present day, 191, 192 Mid-face osteotomy, 216–218
rigid internal fixation, 186, 187 Midface trauma, 157, 159, 160
Matthew Cryer, 95 imaging, 161
Maxillary deficiency, 363, 364 maxilla, 161–165
Maxillary osteotomy modern treatment, 174
complete simultaneous mobilization, 215 nasal bone fractures, 172, 173
description of, 209 zygoma, 165–170
history of, 209 Millesi, Hanno, 320
isolated anterior maxillary segmental Miloro, Michael, 322, 323
osteotomies, 213 Minimally invasive cosmetic procedures
isolated posterior maxillary segmental dermal fillers, 432–438
osteotomies, 214 Egypt, 425
Le Fort classification, 210–212 emphasis, 426
multi-piece segmental osteotomy, 216 needle and syringe, 426
pterygoid plate region, 211 neurotoxins, 427–432
pterygomaxillary disjunction, 212 social media, 426
surgical mobilization of, 209 Missing teeth, 136
Maxillofacial deformities, correction of, 200 Mitchell, Silas Weir, 313
Maxillofacial surgery, distraction osteogenesis Modern anatomical imaging, 17–20
advancements, 357–359 Morton, William T.G., 312
clinical implications, 361, 362, 365 Moss’ theory, 372
craniofacial complex, 355, 356
development, 355
limitations, 355 N
orthognathic surgery, 355 Nasal bone, 157
“over the face” appliance, 356, 357 Nasal bone fractures, 173
Maxillofacial trauma, 364 Natural Magick, 52
Maxillomandibular fixation (MMF), 224 Nerve dissociation, 316
Merrill, Ralph, 323 Nerve reconstruction, 321
Microneurosurgery Neuromuscular blockers, 60–62
contemporary practice of, 321–323 Neuropraxia, 317
development, 317–320 Neurotmesis, 317
future aspects, 323 Neurotoxins, 427–432
Microsurgery Nicolaes Tulp, 23, 24
cellular process of degeneration, 313 Novocaine, 65
nerve physiology and regeneration, 317
nerve repair and grafting, 315
nerve repair, technique of, 319 O
N radialis and N cutaneous antibrachial Obstructive sleep apnea (OSA), 363
lateralis, 315 Obwegeser, Hugo, 218
448 Index

Obwegeser’s second sagittal split technology application, 227, 228

procedure, 205 versatility of, 230
Open reduction and internal fixation Osseointegration, 137
(ORIF), 190 Osteodistraction, see Distraction
Ophthalmology, 93–94 osteogenesis (DO)
Opium, 58 Osteosynthesis, 186, 187, 192
Oral and maxillofacial surgery (OMFS), Otolaryngology, 90–92
94–100, 201 Otto Walkhoff, 18
Oral/head and neck oncologic and
reconstructive surgery fellowship
programs, 270 P
Orofacial clefts (OFCs), see Cleft lip (CL) Paraffin, 433–435
Orthognathic positioning systems (OPS), 228 Paré, Ambroise, 310
Orthognathic surgery Parenteral anesthesia, 57–58
acceptance of, 220, 221 Patelet rich fibrin (PRF), 149
anterior subapical segmental Paul of Aegina, 91
osteotomy, 199 Per-Ingvar Brånemark, 139, 141, 142
bimaxillary advancements, 230 Periodontal disease, 364
bone plates and screws, 224–226 Peripheral nerve surgery, see Microsurgery
description of, 219 Person, Z.N., 317
Discovery Era (1960s – Present), 218 Philipeaux, J.M., 314
distraction osteogenesis, 229, 230 Pierre Fauchard, 95
early mandibular osteotomies, 200, Plastic and reconstructive /surgery, 100–103
201, 204 Platelet derived growth factor (PDGF), 149
complete simultaneous Platelet rich plasma (PRP), 149
mobilization, 215 Polymethylmethacrylate (PMMA), 335
genioplasty, 208 Proplast I, 329
mandibular subapical osteotomies,
207, 208
sagittal split osteotomy, 204, 205 R
global speciality, 222 Radial forearm flap, 294, 295
maxillary osteotomy Radiation oncology
complete simultaneous clinical applications, 242
mobilization, 215 foundations, 242–244
description of, 209 head, 246
history of, 209 history, 241
isolated anterior maxillary segmental modernization, 244, 245
osteotomies, 213 neck, 246, 247
isolated posterior maxillary segmental RadioVisioGraphy system, 19
osteotomies, 214 Random tissue advancements, 282–286
Le Fort classification, 210, 211 Rectus abdominis free flap (RAFF), 298
multi-piece segmental Renaissance period, 95
osteotomy, 216 Rhinoplasty, 412–414
pterygoid plate region, 211 Richard le Barbour, 34
pterygomaxillary disjunction, 212 Rigid fixation, 187, 190
surgical mobilization of, 209 Rivers, William Hales Rivers, 315
mid-face osteotomies, 216–218 Robert Liston, 55
paradigm shift, 218, 219 Robinson’s method, 335
Pioneering Era (1850 – 1960s), 198, 199 Roger Bacon, 93
positive psychosocial impact, 230, 231 Roman Catacombs (200-900 CE), 7
refinements, 223, 224 Roman Empire, 5
revolutionary work, 200 Rood, 321
technical considerations, 231 Royal Army Medical Corps, 73
Index 449

S supraclavicular flaps, 300

Sagittal split osteotomy, 204, 205 tissue engineering, 302
Saint Apollonia, 4 vascular surgery, foundations of, 291–294
Christian martyr, 5 Sushruta (800 BCE), 93
commemorations, 9–11 Swan, Joseph, 310
dental pain, 3 Sydney Sunderland, 318
healer of dental pain, 7
legend, 6–7
patroness of dentistry, 7 T
relics of, 7, 8 Tansini’s latissimus dorsi flap
tooth of, 9 reconstruction, 287
Saint Dionysius, 5 Techmedica model, 337
Santiago Ramón y Cajal, 317 Teflon-Proplast system, 337
Scapular free flap, 297, 298 Temporomandibular joint dysfunction
Schuchardt’s posterior segmental (TMD), 20
osteotomy, 214 Temporomandibular joint (TMJ) surgery
Scientific literature, 135 arthrocentesis, 341–343
Seddon, Herbert John, 317 arthroscopy, 339–342
Segmental subapical osteotomies, 207 gap arthroplasty/discectomy/disc
Seishu Hanaoka, 52 repositioning
Semi-circular mandibular osteotomy, 201, 202 ankylosis, 331
Shebab, 321 clinical symptoms, 330
Sherren, James, 315 condylar degeneration, 329
Simon Hullihen, 96 disc replacement procedure, 332, 333
Sinus lifts, 148, 149 inflammatory foreign body
Sir Harold Delf Gillies, 77–83 reactions, 328
Sir William Kelsey Fry, 82, 83 inter-positional materials, 328
Skoog, Tord, 418 partial and total reconstruction, 333
Smith, James, W., 320 pathologies, 328
Smith, Nathan, 402 proplast I, 329
The Society of Head and Neck proplast-teflon materials, 331
Surgeons, 261–263 PTFE, 329
Spring mediated cranioplasty technique, 382 silastic and Teflon implants, 328
Stevens, Alexander Hodgon, 402 history, 327
Streptococcus septopyaemicus, 116 reconstruction
Submental island flap(SIF), 301 alloplastic joints, 335–340
Superficial musculoaponeurotic system autogenous grafts, 334, 335
(SMAS), 418, 419 3D printed stereolithic model, 228
Supraclavicular artery island (SAI) flap, 300 Tinel-Hoffmann Sign, 316
Supraclavicular flaps, 300 Tinel, Jules, 316
Surgical flaps Tissue engineering, 302
anterolateral thigh flap, 299 Tooth removal, 125
deep circumflex iliac artery, 295, 296 19th century pioneers, 130–132
deltopectoral and pectoral flap, 290, 291 early instruments, 129, 130
facial artery musculomucosal flap, Egyptian era, 127
301, 302 extraction, 127
fibula free flap, 296, 297 Greek, 127, 128
local and regional flaps, 286–290 practitioners, 129
radial forearm flap, 294, 295 pre-history humans, 126
random tissue advancements, 282–286 Total intravenous anesthesia (TIVA), 59
rectus abdominis free flap, 298 Tracheotomy, 56
scapular free flap, 297, 298 Treacher Collins syndrome, 358, 363
submental island flap, 301 Trench warfare, 71
450 Index

Trigeminal neuralgia, 313 Von Ferrara, Gabriele Graf, 310

Triple Entente (Allied), 71 von Langenbeck, Bernhard, 314, 403
Tumor board discussions, 273 Vulpian, Alfred, 314

U W
Ultra-high molecular weight polyethylene Waller, Augustus Volney, 313
(UHMWPE), 337, 338 Wallerian degeneration, 318
Warren, J.C., 310
Warren, J.M., 403
V Wassmund’s inverted ‘L’ type osteotomy, 202
Valerius Cordus, 52 Wassmund’s technique, 202
Vanlair, Constant, 315 Wells, Horace, 312
Varaztad Kazanjian, 73–76 William Osler, 72
Vascular surgery, foundations of, 291–294 Woods, C., 320
Veau, Victor, 404, 406 Wood, William, 310
Veau-Wardwill-Kilner (V-Y) pushback Worthington, Phillip, 323
palatoplasty, 404
Velpeau, Alfred, L.M., 310
Vertical rectus abdominis myocutaneous X
(VRAM) flap, 298 X-rays, 241, 245
Vertical subsigmoid osteotomy (VSSO), 206
Vesalius, Andreas, 310
Vilray Blair, 96 Z
Virchow, Rudolf, 368 Zeiss, 317
Visible Human Project (VHP), 21 Zuniga, John, 322, 323
Vitruvian Man, 23 Zygoma, 160, 165, 166, 168, 169