Our Surgical Past: An Aid to Understanding the Present and a Guide to the Future

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As a resident in general surgery, I came to realize that an understanding of surgical history helped me understand and grasp what was then accepted surgical practice. As an example, it was the era of peptic ulcer surgery and the Billroth II/vagotomy was one of the most common procedures. For a trainee, trying to learn an individual procedure in isolation, without knowing its antecedents, can be a daunting challenge. I recall reading at that time an article on the history of peptic ulcer surgery, which gave me the intellectual perspective I was seeking. Ironically, the Billroth II/vagotomy is rarely practiced today and the treatment of peptic ulcer disease is now predominantly nonsurgical.
Following a senior residency in general surgery, I was, in 1971, unknowingly thrust into the nascent world of craniofacial surgery as a junior resident at the Institute of Reconstructive Plastic Surgery at the NYU Medical Center. As luck would have it, my first rotation was as the resident assigned to the legendary John Marquis Converse. What an exciting experience!
Converse breathed and lived plastic surgery 24 hours a day. At that time, he was working out the technical details of the surgical correction of orbital hypertelorism, including a single-stage repair and preservation of olfaction. Fortunately for me, we got along very well.
Several months later, Paul Tessier arrived from Paris as the Kazanjian Visiting Professor. With Converse assisting, he demonstrated a combined Le Fort III osteotomy/front-orbital advancement. The procedure lasted almost 19 hours. I scrubbed but my role was limited only to harvesting a large iliac bone graft.
Witnessing the development of craniofacial surgery was truly an adventure. For a neophyte plastic surgeon, there was an incredible 3-dimensional anatomy (new territory as compared to my training in the abdominal and thoracic cavities). There were few ground rules and, conversely, few restrictions or boundaries. Planning, by today's standards, was rudimentary.
Computed tomography scans were yet available. I had thought orbital surgery without adequate preoperative imaging was like operating in the “black hole of Calcutta.”
As a resident exposed to surgeons like John Converse, Paul Tessier, Byron Smith, Tom Rees, and Bill Littler (a Converse friend), I was witnessing living plastic surgery history. I heard stories of surgical legends. “Gillies was all head; Mc Indoe all hands.” Gillies told Converse that, after performing the first Le Fort III osteotomy in the late 1940s, “it should never be done again,” as it was too dangerous and he was relieved the patient survived. I also heard that Gillies was impressed by the returning facially injured British prisoners of war who had undergone tibial bone graft reconstruction by “Herr” Lindemann of Germany, these were only a few of the reminiscences conveyed to me over long operations. In addition, I heard discussions on such philosophic subjects as Renaissance concepts of feminine beauty and the role of religious attitudes on surgical modification of the “God-given” face, including Papal bulls, among other.
As one looks at the evolution of craniofacial surgery during its relatively short history, some principles have emerged:
I am optimistic about the future. Plastic surgery of the face will continue to attract the best and the brightest. Residency training will continue to improve, aided by technology and computer learning programs. The history of surgery should be incorporated into the residency/fellowship curriculum, complemented by informal discussions in the operating room. The surgical trainee should be exposed to the struggles of Simon Hullihen in the American frontier in 1849 as he innovatively corrected a severe anterior open bite and restored mastication.
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