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Craniosynostosis Surgery: the Legacy of Paul Tessier

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Craniosynostosis Surgery: the Legacy of Paul Tessier Neurosurg Focus 36 (4):E17, 2014 ©AANS, 2014 Craniosynostosis surgery: the legacy of Paul Tessier Historical vignette *MICHAEL G. Z. GHALI, PH.D.,1 VISISH M. SRINIVASAN, M.D.,2 ANDREW JEA, M.D.,2 AND SANDI LAM, M.D.2 1Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania; and 2Department of Neurosurgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas Paul Louis Tessier is recognized as the father of craniofacial surgery. While his story and pivotal contributions to the development of the multidisciplinary practice of craniofacial surgery are much highlighted in plastic surgery literature, they are seldom directly discussed in the context of neurosurgeons. His life and legacy to craniosynostosis and neurosurgery are explored in the present paper. (http://thejns.org/doi/abs/10.3171/2014.2.FOCUS13562) KEY WORDS • Paul Tessier • craniofacial surgery • craniosynostosis • history HE history of craniosynostosis surgery is an inter- disorders that are the consequence of premature fusion of esting one and has been well discussed in the re- one or more cranial sutures. In a majority of cases, cra- cent neurosurgical literature.30 However, operative niosynostotic disease involving a single suture is not asso- Tintervention for craniosynostosis is not a field exclusive ciated with medical or neurological complications,2,18 and to neurosurgeons, with one of the most important contrib- in these cases surgery is indicated primarily for cosmetic utors to the development of modern techniques hailing purposes. With multiple suture involvement, complications from the field of plastic surgery—Paul Louis Tessier (Au- including, but not limited to, brain growth restriction, hy- gust 1, 1917–June 6, 2008). To fully appreciate the his- drocephalus, and blindness constitute medical indications tory and evolution of craniosynostosis surgery, one must for surgery, in addition to aesthetic restoration. Early op- understand both Tessier’s direct contributions to this con- erative intervention (in patients prior to 6 months of age) dition proper as well as his indirect contributions through has been reported to achieve good results1,6,8,9,12,19,29,40 but the development of operative strategies employed gener- is associated with an increased incidence of reoperation. ally in the correction of craniofacial deformities. What Conversely, late operative intervention less frequently re- we now consider to be the “routine treatment” of cranio- quires reoperation and enables intraoperative correction, synostosis and other craniofacial pathologies is based in but often involves more extensive reconstruction. the many principles and methods pioneered by Tessier. Craniosynostosis is most frequently nonsyndromic To date, Tessier’s impact on neurosurgery from his work and monosutural but may be associated with a known ge- on craniosynostosis and facial trauma has not been dis- 30 netic disorder, such as Crouzon or Apert syndrome. The cussed. In fact, multiple disciplines, including plastic latter may involve multiple synostoses and often require surgery, head and neck surgery, oral-maxillofacial sur- more extensive and staged reconstruction. Nasal and oral gery, ophthalmology, and neurosurgery, have been deeply airway functions are often affected in these cases. influenced by Paul Tessier’s work. Simple synostectomy was first performed by Lan- nelongue (1890)23 and Lane (1892).22 In many patients, the Background operation was performed late and resulted in consider- able reossification, which led to reestablishment of brain Craniosynostosis constitutes a heterogeneous group of growth restriction. Moreover, in an early case series of 33 patients, Jacobi (1894)20 reported a high operative mortal- Abbreviation used in this paper: CFD = craniofacial dysostosis. ity rate (15 deaths). The high failure rate and mortality * Drs. Ghali and Srinivasan contributed equally to this work. burden in these early cases had two possible antecedents: Neurosurg Focus / Volume 36 / April 2014 1 Unauthenticated | Downloaded 10/06/21 06:02 AM UTC M. G. Z. Ghali et al. 1) microcephaly was misdiagnosed as craniosynostosis or 2) the surgery was performed late; they were possibly less associated with a high surgical risk itself.7,8 These early surgical techniques were less than ideal, rarely achieving a satisfactory cosmetic outcome in patients with cranio- synostosis. More severely affected patients, such as those with craniofacial dysostosis (CFD), were simply left un- treated, being deemed “inoperable.” Early Life and Training Paul Tessier was born in 1917 to Ernest and Solange Tessier, who hailed from a line of wine merchants in a small town, Héric, near Nantes, France. Originally, Tes- sier aspired to work in forestry or join the navy but was prevented by poor health. Perhaps spurred by his moth- er’s battle with tuberculosis, he instead pursued a career in medicine. He attended medical school in Nantes27 from 1936 to 1943. During the German occupation of France in World War II, his training was interrupted by mili- tary service. In 1941, he was taken as a prisoner of war.41 A year later, his professor in infectious diseases found him to be critically ill with typhoid myocarditis and con- vinced his captors to release him. He returned to Nantes and finished medical school, only for his hometown to be destroyed in a bombing raid the following year. He ven- tured north, to Paris, to continue his surgical residency and pursue his newfound interest in cleft palate and plas- tic surgery (Figs. 1 and 2).21,43 Early Career His first appointment in Paris was with Maurice Vi- renique, a maxillofacial surgeon. They worked together FIG. 1. Photograph of Paul Louis Auguste Ernest Tessier (August at the Red Cross military hospital and moved to Hôpi- 1, 1917–June 6, 2008). Reproduced with permission from A Man from tal Foch,21 where Tessier gained tremendous experience Héric: The Life and Work of Paul Tessier, MD, Father of Craniofacial in treating facial injuries at the Maxillofacial and Burn Surgery. Figure 17.2. Copyright S. Anthony Wolfe. Photo taken by Jim Center. Then he moved to the pediatric surgery service Fletcher, ca. 1975. at Hôpital St. Joseph and worked with George Huc (a prominent orthopedist); he gained exposure to plastic Tessier was influenced greatly by his own unique set surgery and orthopedics. When Virenique died, Tessier of multidisciplinary training and by individual mentors was named chief of plastic surgery at Hôpital Foch. By who were giants in each of those fields. In his inaugural this time, he had garnered experiences in general surgery, address to the International Society of Craniofacial Sur- pediatric orthopedics, and otorhinolaryngology.43 Still, he gery in 1985, he credited his training (and collaborators) sought to enhance his training further. in pediatric orthopedics (G. Huc),43 facial trauma (M. Vi- Between 1946 and 1950, he made frequent trips to renique), facial reconstruction (H. Gillies, A. McIndoe), the United Kingdom, for 1–2 months at a time, to observe ophthalmology (G. Sourdille, P. Francois), cleft palate clinical practice and techniques of the surgical masters surgery (P. Petit), and neurosurgery (G. Guiot, J. Roug- who practiced there.21,43 He sought out Sir Harold Gillies, erie). 24 This wide range of training was not set up for Tes- an otolaryngologist based in London, who is arguably sier in any formal manner—he sought it out.43 considered the father of plastic surgery. Gillies performed After Tessier began to establish himself on the na- the first maxillary osteotomies on a patient with Crouzon tional level as a master of craniofacial pathology, he was syndrome,11 one of the congenital facial syndromes that consulted in 1957 about a patient with facial deformity would later become the cornerstone of Tessier’s career.25 of an extreme nature—a young man with Crouzon syn- During his many visits, he observed, performed surgery, drome, presenting with severe facial retrusion. The opera- took copious notes, and developed a strong basis in the tion he sought to perform had been previously tried by his fundamentals of craniofacial surgery. At that time, rapid mentor Gillies, who had undertaken the first Le Fort III advances in plastic surgery were occurring in response to osteotomy in 1950 to correct the same deformity. How- severe wartime injuries. Tessier described his experiences ever, the newly positioned bone relapsed, and Gillies did with plastic surgery pioneers Sir Harold Gillies and Sir not attempt the surgery again. Gillies commented “never Archibald McIndoe as “a revelation.”21 to do it”11,21,25,44 and had deemed the condition inoperable. 2 Neurosurg Focus / Volume 36 / April 2014 Unauthenticated | Downloaded 10/06/21 06:02 AM UTC The legacy of Paul Tessier of severe teleorbitism.25 After much deliberation, Tessier had determined that the only way to achieve sufficient cor- rection would be through an intracranial frontal approach to the midface and interorbital region. Guiot, his feet up on his desk, looked up at the ceiling for a moment, then replied: “Pourquoi pas?” (Why not?) (personal communi- cation, S. A. Wolfe, December, 31, 2013). This rhetorical question captured the spirit of Tessier’s innovative develop- ment of craniofacial surgery and later became the motto of the International Society of Craniofacial Surgery. This answer shattered the wall that existed between the cra- nial region and the face, and between neurosurgeons and plastic surgeons, and opened up the way for the development of a con- structive collaboration.25 Their boldness was complemented by thorough- ness; prior to attempting the procedure, Tessier and Guiot planned every step, anticipated every potential complica- 21,43 tion, and practiced on cadavers for well over a year. FIG. 2. Photograph of Tessier and his wife Mireille at the Lido, 1971. Together, they achieved a result that would have had been Reproduced with permission from A Man from Héric: The Life and Work 43 of Paul Tessier, MD, Father of Craniofacial Surgery. Figure 15.1.
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