Facial plastic surgery: Subspecialty helps otolaryngology define its boundaries

Otolaryngology H e a d a n d N e c k Surgery JULY 1996

VOLUME 115

NUMBER I

CENTENNIAL SERIES

Facial plastic surgery: Subspecialty helps otolaryngology define its boundaries ROBERT L. SIMONS, MD, FACS,and T. SUSAN HILL

FOREWORD AND ACKNOWLEDGMENTS

Covering 100 years of history in a few pages for this centennial publication, I have learned, is a far different task from covering that same period in the space of an entire book. The book to which I refer is Coming of Age:

A Twenty-fifth Anniversary of the American Academy of Facial Plastic and Reconstructive Surgery, which I edited in 1989 with T. Susan Hill, now executive director of the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS). For that book, we put the subspecialty under a microscope, digging through mountains of archival material and interviewing dozens of persons to piece together a story that began with modern facial plastic surgery's emergence during the late nineteenth century and ended with its attaining maturity as otolaryngology's largest subspecialty. For this article the editorial process has been more akin to looking at the subspecialty through a telescope. Regarding the vast sweep of history through that lens, it is the stars that shine most brightly--those brilliant, farsighted surgeons who attempted the earliest facial plastic procedures, grasped their tremendous potential for patient care, and pushed the boundaries of an

From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology(Dr. Simons), University of Miami School of Medicine; and the American Board of Facial Plastic and Reconstructive Surgery (Ms. Hill): Received for publication Feb. 5, 1996; accepted Feb. 5, 1996. Reprint requests: Robert L. Simons, MD, 16800 NW Second Ave., Suite 607, N. Miami Beach, FL 33169. Otolaryngol Head Neck Surg 1996;115:1-14. Copyright © 1996 by the American Academy of Otolaryngology Head and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 +0 23/t/72382

old specialty until it naturally extended to embrace this new subspecialty. In this condensed retelling, we hope to bring to life the history of facial plastic surgery by populating these pages with the people who made it happen. For the full story, we invite you to read Coming of Age, copies of which are still available through the American Academy of Facial and Reconstructive Plastic Surgery. (AAFPRS). We thank the Educational and Research Foundation of the AAFPRS for permission to quote liberally from that book. Thanks also go to two AAFPRS past presidents, Richard T. Farrior and Roger L. Crumley, for additional material supplied for this article. Finally, appreciation must be expressed to the many surgeons whose actions contributed to the events recorded here. We apologize in advance if, through constraints of space or inadvertent omission, we have failed to acknowledge adequately the contributions of any one of facial plastic surgery's many significant leaders. THE FATHER OF M O D E R N F A C I A L PLASTIC SURGERY

The history of modern facial plastic surgery began more than 100 years ago, when a few men independently began to explore a new surgical fi'ontier of reconstructive and functional repairs that also improved appearance. As one might expect, they had trained in different specialties, including otolaryngology, and so brought to the work somewhat different knowledge and skills. By observing one another--there were few formal training programs at the time--these surgeons rapidly improved and expanded the procedures each could perform. One surgeon in particular stands out from this time.

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Fig. 1. Early otolaryngologist John Orlando Roe (left) performed the first intranasal rhinoplasty in 1887. However, it is Jacques Joseph (middle) whose monumental contributions to facial plastic surgery earned him a place in history as the father of the modern subspecialty. "Everyone in the beginning used some modifcation of Joseph's original ideas and then c h a n g e d them," recalled John J. Conley (right). Conley's own reputation as the foremost head and neck cancer surgeon in the world lent tremendous stature to the young AAFPRS,which he served as president in 1966. In 1974, he led the AAOO. (Left, From McDowel F. Silvergirl's surgery. Arlington Heights, II1.: Educational Foundation of the American Society of Plastic and Reconstructive Surgery, 1975. Middle, From Natvig P. Jacques Joseph: surgical sculptor. Philadelphia: WB Saunders, 1982. Right, Courtesy Richard L Farrior.)

Fig. 2. In this 1922 photograph, taken in the office of Professor Friedrich Kopsch in the Anatomical Institute in Berlin, Joseph (seated at far left) poses with surgeons who c a m e to study his facial plastic techniques. Le# to right, seated: Joseph, Kopsch and an unknown Spanish surgeon. Standing: Jacques Maliniac, Gustave Aufricht, and Zoltan Nagel. Aufricht and another Joseph trainee, Joseph Safian, brought Joseph's rhinoplasty techniques to the New York area in the 1930s. (From Natvig P. Jacques Joseph: surgical sculptor. Philadelphia: WB Saunders, 1982.)

Jacques Joseph (1865-1934) was born Jakob Lewin Joseph, second son of Rabbi Israel Joseph, in K6nigsberg, Prussia. By 1892 he was working as the assistant to orthopedic surgeon Professor Dr. Julius Wolff in

Berlin, when he became interested in facial plastic surgery. Joseph's first case was a young boy who refused to attend school because he suffered such ridicule from classmates for his large, protruding ears. In 1896 the boy's mother approached Joseph for advice, asking if there might be surgical relief for her son's affliction. Although Joseph was unaware of such surgery having been performed before, he believed it was possible and, after careful planning, operated successfully. His achievement brought him early renown when he reported it to the Berlin Medical Society; however, it also cost him his job with Wolff, who felt that Joseph had risked the reputation of Wolff's clinic by performing the maverick procedure. Two years later, Joseph performed his second facial plastic procedure on a 28-year-old man whose extremely large nose caused him such embarrassment that he could not bear to appear in public. The man had heard about the ear reduction Joseph had performed and wondered whether he might also be able to reduce the size of a nose. Joseph thought this too was possible, but it was sufficiently complicated that he should practice first on a cadaver, which he did. Again he succeeded and in May 1898 reported this achievement to the Berlin Medical Society. Joseph's report included a theory that Joseph had been developing, which postulated that the psychological aspect of aesthetic surgery was as important as its

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Fig. 3. Samuel Foman (left) went to Europe to study with Joseph in the 1930s a n d then organized a course around Joseph's methods. A m o n g the 750 otolaryngologists he taught were 2 - - M a u r i c e H. Cottle (middle) and Irving B. G o l d m a n (right)--who went on to d e v e l o p their o w n courses. The loyal followers of all three men formed societies, a n d Foman's a n d Goldman's societies m e r g e d to create the AAFPRS in 1964. (Courtesy Lenore Davis Foman, Pat A. Barelli, and Robert L. Simons.)

Fig. 4. Otolaryngology withheld its a p p r o v a l of facial plastic surgery until Foman's course c a u g h t the attention of G e o r g e Coates (left), AAOO president in 1939, a n d Dean Lierle (right), AAOO president in 1960. Lierle strongly believed that facial plastic surgery b e l o n g e d in university o t o l a r y n g o l o g y training programs. (Courtesy John Atkins a n d Richard T. Farrior.) physical success. According to the theory, a person whose looks caused social or economic disadvantage was as severely afflicted as a person with a debilitating disease. This was a courageous and compassionate view in light of its being outside the mainstream of medicine, whose "serious" surgeons scorned the use of their skills

for cosmetic purposes. It was also contrary to Joseph's Prussian background, which sternly admonished one to make do with what life dealt. Joseph called the desire to look normal "antidysplasia," not vanity. With his early success and his compassionate views, patients soon flocked to Joseph. Other surgeons also

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Fig. 5. Before the days of television, students watched a master surgeon from the distant rows of an operating theater, as shown a b o v e in Irving Goldman's 1961 class. In the top row, Goldman (center) stands with his "lieutenants": Hueston King, Samuel M. Bloom, Trent W. Smith, Henry A. Thomas, Irvin J. Fine, Goldman, Sidney S. Feuerstein, Howard Bancks, Lewis J. Ruffedge, Charles Aronson, and Robert M Hui. Among the m a n y students who went on to make major contributions to facial plastic surgery were W. E. G o o d m a n (second row, fifth from right), who 14 years later helped to introduce the external rhinoplasty to American surgeons', F. F. Rubin (firstrow, secondfrom right), who designed the Rubin nasal instruments; and David King (first row, far right), who later b e c a m e a member of the Goldman course faculty. (Courtesy Robert L. Simons and Sidney Feuerstein.)

Fig. 6. After courses, G o l d m a n typically gathered with his favorite trainees, holding court and brandishing his ubiquitous cigar. From left: Goldman, unknown surgeon, William Schwartz, unknown surgeon, Lionello Ponti, Irvin J. Fine, and Joseph Freeman. (Courtesy Robert L. Simons and Sidney Feuerstein.)

came to watch and learn. Before long, Joseph was widely reputed to be the premier facial plastic surgeon in Europe. His work ultimately earned him a place in history as the father of modern facial plastic surgery. Meanwhile, other surgeons already had begun to explore the same territory. In 1845 another German,

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Fig. 7. The avid interest of otolaryngologists in facial plastic surgeryaftracted many teachers, including general plastic surgeon Richard C. Webster, shown here atthe 1985 Mt. Sinai rhinoplasty course. (Courtesy Richard T. Farrior.)

Johann Friedrich Dieffenbach (1792-1847), published a paper that described a procedure for nose reduction using external incisions very similar to those used by Joseph in 1898. In 1881 an otolaryngologist, Edward Talbott Ely, performed the first correction of protruding ears on a 12-year-old boy at the Manhattan Eye, Ear and Throat Hospital in New York (he corrected one ear at a time, with a 6-week interval). Robert F. Weir (18381927), a renowned professor of surgery at the College of Physicians and Surgeons in New York City, claimed to have performed a four-stage rhinomiosis totalis (total nose reduction) in 1885. A fourth surgeon, John Orlando Roe (1848-1915), is credited with performing the first intranasal rhinoplasty in 1887. Roe, who practiced in Rochester, New York, was an otolaryngologist by training, and he had published more than 30 papers on various otolaryngologic subjects before his historic rhinoplasty. Four years later he made history again when he published an article describing the endonasal hump removal in five patients, as well as the use of a spring wire for internal splinting of the nose. Nonetheless, it was Joseph who became world famous. During World War I, he served as director of the Division of Facial Plastic Surgery of the Charit6 Hospital in Berlin. Under emergency conditions, he restored

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Fig. 8. EarlyleadersoftheAAFPRSstrovetoexpandfacialplasticsurgerywithinotolaryngology training programs, while also developing courses for continuing medical education. Left, Five major contributors to these efforts were (from left) Samuel Bloom, the second AAFPRStreasurer, and past presidents William Wright, Jack Anderson, Ira Tresley, and Carl Patterson. Right, Patterson' s leadership continued for years, and he w e l c o m e d the involvement of other early leaders as shown in this informal gathering (from left): Patterson, Walter E. Berman, and Trent W. Smith. (Courtesy Carl Patterson.)

Fig. 9. The faculty of Rhinoplasty 1984 illustrates the traditional commitment of AAFPRS leaders to teach the next generation of surgeons. Pictured a b o v e are (firstrow, from left) Leslie Bernstein, Ted A. Cook, Irvin J. Fine, Richard C. Webster, Robert L. Simons, Trent W. Smith, Richard T. Farrior, and Rudolph Meyer; and (second row, from left) Tony R. Bull, Charles W. Gross, Sidney S. Feuerstein, Jack Anderson, William K. Wright, E. Gaylon McCollough, Howard Diamond, Morey L. Parkes, Walter E. Berman, Charles J. Krause, G. Jan Beekhuis, and H. George Brennan. (Courtesy Robert L. Simons.)

the war-ravaged faces of innumerable German soldiers. He studied and classified their deformities, later writing many papers and his monumental book, Rhinoplasty and Other Facial Plastic Surgery, wherein he first recorded his theory that antidysplasia was a treatable disease.

Fig. 10. At Rhinoplasty 1994, senior surgeons were joined on the faculty by the rising stars of the next generation, many of whom had been students at earlier courses. Pictured (from left) are J. Regan Thomas, Fred J. Stucker, Wayne F. Larrabee, Calvin M. Johnson, Jr, M. Eugene Tardy, H. George Brennan, Dean M. Toriumi, Ferdinand F. Becket, Howard W. Smith, Norman J. Pastorek, Robert L. Simons, Paul H. Toffel, Ira D. Papel, Russell W. H. Kridel, E. Gaylon McCollough, Ted A. Cook, Devinder S. Mangat, Fernando Pedroza, Larry D. Schoenrock, Tony R. Bull, Peter A. Adamson, John L. Frodel, Jr, and Claus D. Walter. Not pictured: Leslie Bernstein. (Courtesy Robert L. Simons.)

WORLD WAR I

During the years leading up to World War I, a number of developments changed the practice of surgery in general and of otolaryngology in particular. Before the

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Fig. 11. Richard L. Goode's abiding interest in the AAFPRS Foundation's fellowship program m a d e him the logical successor in 1984 to AAFPRS President Howard W. Smith, whose lifelong interest in scholarship led him to establish-with Robert L. Simons--the Founders Club in 1986. (Courtesy AAFPRSarchives.)

turn of the century, much of otolaryngology was limited to the opening and drainage of abscessed cavities and the removal of pathologic tissue. During the early twentieth century, medical advancements transformed otolaryngologic surgery from destructive to constructive. Notably, anesthesia methods had been developed, and antisepsis was known and routinely used, so that complex facial surgery could be attempted successfully. Edison's development of the lightbulb made it possible to operate in cavities and other areas previously not sufficiently illuminated for surgery. These developments reduced operating hazards and, combined with a better understanding of clinical physiology, allowed otolaryngologists to focus on reconstructive work. They began operating on cleft lips, cleft palates, paraffinomas, and other head and neck tumors. The success they achieved was remarkable even by today's standards and nothing short of amazing given the absence of antibiotics, blood transfusions, and so on. Still, no surgical advances to date adequately prepared physicians for the sheer savagery of warfare in the trenches of World War I. Sophisticated weaponry rained explosives onto hundreds of thousands of entrenched soldiers, producing a huge population of facially disfigured men on whom to perform reconstructive surgery. Surgeons of many specialties worked side-by-side on both sides of the trenches--otolaryngologists, oral surgeons, general surgeons, dental sur-

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Fig. 12. During the 1970s and 1980s, facial plastic surgery b e c a m e recognized as a national medical specialty society, winning seats on the AMA Plastic Surgery Section, the ACS Board of Directors, the AMA House of Delegates, and more. Shown above, representing the subspecialty at the AMA House of Delegates in the early 1980s, are (from left) J. Regan Thomas and Fred J. Stucker. (Courtesy AAFPRS archives.)

geons, ophthalmologists, and brain surgeons. They improvised and collaborated to meet each horrific need as it arose, inventing on the spot many of the procedures that comprise the repertoire of the modem facial plastic surgeon. While Joseph worked in Berlin, Sir Harold Gillies, an otolaryngologist, headed a vast treatment center for allied casualties in Sidcup, Kent, U.K. During and after the war, Gillies, like Joseph, attracted surgeons from many countries who came to learn plastic surgery techniques from him. One otolaryngol0gist who was greatly influenced by his wartime experience with Gillies was Ferris N. Smith, who returned to the University of Michigan after the war and became one of the most important facial plastic surgeons of that era. Smith recorded his experience in a paper titled "Plastic Surg e r y . . . Its Interest to the Otolaryngologist," which he presented at the 1920 meeting of the American Medical Association (AMA) Section on Laryngology, Otology and Rhinology. Interestingly, the postwar practices of Gillies and Smith gradually evolved toward general plastic surgery, and both men eventually closed their training to fellow otolaryngologists. Among Smith's trainees were two men, Clarence Straatsma and Reed Dingman, who later became chiefs of plastic surgery at

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Fig. 14. Recognition of the ABFPRSas a board equivalent to a primary board of the ABMS is in large part the result of the efforts of surgeons who have worked tirelessly to develop and maintain the ABFPRSexamination. Among key contributors hand-picked by Peter A. Adamson are (from left): Lee D. Rowe, Shan R. Baker, Ira D. Papel, and Dean M. Toriumi. Not pictured are Donn R. Chatham and Leslie Bernstein, whose efforts as current and immediate past chairs of the ABFPRS Resource Development Committee a d d e d significantly to the examination process. (Courtesy ABFPRSarchives.)

Fig. 13. The ABFPRS was incorporated in 1986 to provide facial plastic surgeons with a pathway for recognition of their training and expertise. Shown are (from left) third ABFPRS President J. Regan Thomas and second ABFPRS President Robert L. Simons. Not shown is first ABFPRSPresident E. Gaylon McCollough. (Courtesy ABFPRSarchives.)

Columbia University in New York and the University of Michigan, respectively. When the war ended, wartime otolaryngologists were determined to practice and learn more about this fascinating new field of facial plastic surgery. Almost immediately they encountered difficulties. They found that their expertise was not recognized in certain quarters, nor were they welcome any longer to learn in certain operating rooms. Gillies himself was shut out by Hyppolyte Morestin, an outstanding reconstructive surgeon at whose side Gillies had worked throughout the war. The event marked the beginning of a turf war between general surgeons and otolaryngologists that continues to this day. It also underscored two needs that would challenge facial plastic surgeons for years to come: the need to develop formalized training within otolaryngology and the need to win recognition for their expertise. PLASTIC S U R G E R Y O R G A N I Z E S

The attempt by general surgeons to exclude otolaryngologists and to claim plastic surgery techniques lbr themselves dismayed regional surgeons who, after all,

Fig. 15. Building bridges within the otolaryngology specialty for the subspecialty of facial plastic surgery was the forte of these three surgeons (from left) John Kirschner, chair of otolaryngology at Yale University, Richar d T. Farrior, and John J. Conley. (Courtesy Richard T. Farrior.)

developed and used many of those techniques.i Moreover, the proprietary attitude contrasted sharply With the spirit of open inquiry that had served patients s.o well during the war. At that time, there was no recognized specialty of plastic surgery, as evidenced by the Staffing in the U.S. Surgeon General's plastic surgery service. An orthopedic surgeon (Vilray R Blair) ran the show,

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assisted by a general surgeon (Robert H. Ivy), and the chief of plastic surgery at the federal government rehabilitative hospital was an otolaryngologist (Lee Cohen). An even more diverse mix of specialties was represented among the surgeons who founded the American Board of Plastic Surgery (ABPS) in 1937. Representing otolaryngology was Gillies, who eventually was succeeded by his student Ferris Smith. To the disappointment of fellow otolaryngologists, Smith eventually adopted the attitude that came to characterize many ABPS diplomates. A notable exception was ABPS diplomate Richard C. Webster, who deplored the fact that, once "the plastic surgical board prescribed its method of training, many of these men tended to forget or dismiss the fact that they had acquired much of their skill in reconstructive or cosmetic surgery as members of their originating disciplines. Although it is understandable that this group developed pride in its achievements, many of its members began to believe or profess that the only way to do this was their way." Webster' s beliefs led him to a lifelong association with the AAFPRS, to which he was elected president in 1976. O T O L A R Y N G O L O G I S T S UNDETERRED

With training opportunities thus limited, surgeons were all the more eager to study with Jacques Joseph, whose reputation was at its zenith after the war. Internships and residencies were not yet widespread, and surgeons entered into paid preceptorships with Joseph, whose enormous practice included facelifts, otoplasties, and general plastic procedures of the body. Of the many Americans who traveled to Berlin to observe Joseph, none was more important to otolaryngology than Samuel Foman (1889-1971). It was Foman's destiny to transfer Joseph's knowledge to otolaryngology. Neither a surgeon nor an otolaryngologist, Foman was an anatomist whose great interest was teaching, at which it is said he was brilliant. Foman became interested in facial plastic surgery during World War I (he trained medical officers in the U.S. Army Medical Reserve Corps) and lamented the lack of books and formal training on the subject. A marvelously thorough researcher and writer, Foman undertook the compilation of all known work on facial plastic surgery to ensure that his students had a text. His research for the book took him to Europe and to Joseph around the time the ABPS was founded. Foman watched as general plastic surgeons began to monopolize plastic surgery procedures, blocking regional specialists from using them by restricting hospital privileges, refusing admittance to operating rooms, barring access to journals, and rejecting attendance at courses and meetings. Foman, whose life exemplified the open teaching ethos that would become

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the hallmark of facial plastic surgery, was especially irked that general plastic surgeons covered their work the moment he entered the operating room. He made up his mind to do something about this practice. He decided he not only would find out everything he could about facial plastic surgery but also would teach it--to otolaryngologists. In 1940 Foman organized a course, which over the years attracted more than 750 otolaryngologists. One of the few places in the country that offered formal training in facial plastic surgery, Foman's course caught the eye of two otolaryngologists. First, George Coates, editor of the prestigious Archives of Otolaryngology and professor of otolaryngology at the University of Pennsylvania, learned of Foman. His encouragement to the otolaryngologists at the University of Pennsylvania and their associated hospitals to take Foman's courses earned him credit for advancing facial plastic surgery in otolaryngology. Through Coates, Foman met Dean Lierle, chairman of the Department of Otolaryngology at the University of Iowa, longtime secretary of the American Board of Otolaryngology (ABO), and probably the most powerful man in otolaryngology in the 1950s and 1960s. Lierle's department, said to be one of the finest in the world at that time, was the only one providing full facial plastic surgery training within the structure of a residency program. He opened the doors of academia to Foman and made his course acceptable to otolaryngologists. Even with Foman' s acceptance by Coates and Lierle, facial plastic surgery was not immediately embraced by otolaryngology. Although increasing numbers of otolaryngologists used plastic surgery procedures whenever it was necessary in their work--to shift tissues in ear surgery, to correct deformities caused by cancer ablations, to repair congenital deformities, and to provide other functional and aesthetic improvements--the attitude persisted that facial plastic surgery was a bit frivolous. To be taken seriously, the emerging subspecialty apparently would have to establish itself independently, developing its own training programs and attracting enough surgeons to achieve viability as a noteworthy entity. M O R E COURSES A N D STUDY G R O U P S

During the next two decades, courses and study groups proliferated as facial plastic surgeons independently pursued training and recognition. While Foman' s course continued in New York, two of his students established their own courses, which focused on their own special interests. Maurice H. Cottle (1898-1981) returned from his Foman courses to concentrate on nasal function, and in

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the late 1940s began to teach rhinology in a rigorous course that ran from 8 AM to 11 PM for 7 to 10 days at a stretch. He both charmed and intimidated his students with lectures that mixed his immense knowledge of anatomy, surgery, philosophy, religion, art, music, and psychiatry. From each student he demanded perfection because rhinology itself, he believed, was such a stern taskmaster. Its mastery required a lifetime, and Cottle himself devoted the first part of his life to the septum, the next decade to the nasal valve, and the next 10 years to the pyramid. During the final part of his life he was concerned with rhinologic functional testing. Indeed, Cottle was concerned with function all of his life. His extensive work in the relationship of the nose to the heart and lungs and in the development of simple breathing tests that can signal potential heart trouble are still basic today. After his studies with Foman, Irving B. Goldman (1898-1975) pursued his single-minded interest in aesthetic surgery of the nose, which led him in 1953 to organize a two-week course at Mt. Sinai Hospital in New York. The course--which continues to this day under the leadership of William Lawson, with the longtime support of two surgeons who graduated from Mt. Sinai residencies to eventually assume AAFPRS presidencies, Robert L. Simons (AAFPRS president in 1985) and Frank M. Kamer (AAFPRS president in 1988)---is still considered one of the jewels in the residency program. Goldman tried any new technique he thought would improve the nose. By 1957 he had developed the so-called "Goldman tip," in which he cut the angle between the mesial and lateral crura and sutured the mesial crura together, resulting in improved tip projection. He published his procedure in a paper titled "The Importance of the Mesial Crura in Nasal Tip Reconstruction" in the Archives of Otolaryngology in 1957. Goldman's superb surgical skills stood,in sharp contrast to his rough-and-ready character. A heavy smoker and former boxer, he was not genteel in either his appearance or his interactions with others. He demanded absolute loyalty among his students, and his dogmatic manner either inspired others or completely turned them off. Beyond the formal courses of Foman, Cottle, and Goldman, ad hoc study groups ruled the day. Word would go out that a master operator had scheduled a particular procedure the next day, and surgeons would fly into town to watch and critique the operation. "That's how the leadership stimulated others to teach," Webster recalled, by making time in their own busy practice schedules to share knowledge with the younger surgeons. In this way, "the pool of knowledge just expanded," Morey L. Parkes said. Moreover, a new generation of leaders was trained.

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Parkes, who would go on to serve as AAFPRS president in 1968, made repeated trips to learn rhinoplasty techniques from Foman, as others would later fly to Parkes' Beverly Hills office to learn the nuances of other facial plastic surgery procedures. Jack R. Anderson, the dynamic first secretary of the AAFPRS, learned facelifts from Ira Tresley (AAFPRS president in 1969) in Chicago, where Anderson (AAFPRS president in 1971) flew on 25 separate occasions to watch the master at work. Anderson also found Morris Feldstein, an ophthalmologist at Mt. Sinai who was willing to teach blepharoplasties, and flew there to learn that procedure. Sidney S. Feuerstein (AAFPRS president in 1980) flew to Chicago on many occasions to learn otoplasty from Oscar Becket. Through these informal study groups, an essential body of knowledge about facial plastic surgery developed. Richard T. Farrior (AAFPRS president in 1967, American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] president in 1990) vividly recalls hosting such a meeting for a group in Tampa, Florida, which included Jack Anderson, Oscar Becker, John Dickinson, Louis Feit, Jesse Fuchs, Irving Goldman, Benito Rish, Abraham Silver, Ira Tresley, and William Wright. He operated before his peers and then engaged in their constructive criticism and anecdotal experiences. These sessions built on basic principles that were then taught in otolaryngology residencies but applied these principles in new ways. Creating these new training opportunities attracted a certain individual. Early facial plastic surgeons burned with the fire of an inner determination, had strong personalities, and sparred over philosophic differences. However, their common thirst for learning created a bond that they transmitted to their disciples, who in turn spread the word, drawing increasing numbers of otolaryngologists to facial plastic surgery. Contributing to the flood of interest were certain external events. The discovery of antibiotics and chemotherapeutic agents in the 1940s eliminated the lifethreatening infections that comprised the practice of many otolaryngologists. Meanwhile, the need for facial plastic surgeons grew with the rising incidence of cancer and the advent of the automobile, which added a new source of facial trauma. Also, a more appearance-oriented society increased the demand for cosmetic work, which had become more acceptable. By 1960 grassroots interest in facial plastic surgery among otolaryngologists had spread across the country. If the center of facial plastic surgery in the 1940s and 1950s was New York, with Foman and Goldman and their students and with such men as Abraham Silver, Howard Diamond, and Louis Felt, it soon had followers

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(including future AAFPRS leaders) in California-among them, Walter E. Berman (AAFPRS president in 1972), Ed Lipsett, Parkes, and Jesse Fuchs, whose practice came into Parkes' hands after Fuchs met an untimely death at the height of his career. In the Midwest, the big names were Cottle, Tresley, Becket, and of course Lierle. Eventually this tremendous American interest in facial plastic surgery spread across the Atlantic Ocean. A series of courses, cosponsored by the AAFPRS, was organized by Horst Wullstein and his wife Sabrina, also a physician, at the University of Wurzburg. The courses attracted Tony Bull of England, Claus Walter of Germany, and others, who eventually formed the European Academy of Facial Surgery, also known as the Joseph Society, named in honor of the modem subspecialty's founder. F A C I A L PLASTIC SURGERY O R G A N I Z E S

It was time for mainstream otolaryngOlogy to take notice; Certainly the general plastic surgeons had. An aggressive campaign to disparage facial plastic surgeons culminated in a Harper's Bazaar article in 1960, which for the first time told the public to protect itself from otolaryngologists who claimed to be qualified to perform nasal plastic surgery: "Be sure your surgeon has the added years of study and experience which the American Board of Plastic Surgery certification guara n t e e s . . , ask a surgeon point blank to see his board c e r t i f i c a t i o n . . . " the article said. The claim caused an uproar, with facial plastic surgeons asking the AMA to censure the general plastic surgeons for unethical behavior. When the AMA did not it was believed that facial plastic surgeons had t o o much the reputation of rebels--facial plastic surgeons appealed to otolaryngology for support. In a historic meeting at Chicago's Palmer House in 1961, Anderson presented a collection of 15 years' worth of "crassly commercial" statements published by the general plastic surgeons, each subtly defaming the ability of otolaryngologists to perform facial plastic surgery. His evidence convinced otolaryngology (then represented by the American Academy of Otolaryngology and Ophthalmology [AAOO]) to ask the Advisory Board of Medical Specialties (ABMS; the precursor of the American Board of Medical Specialties) to reprimand the ABPS. Although the ABMS did so, the effect was negligible because the American Society of Plastic and Reconstructive Surgery later took up the defamation campaign. The truly historic aspect of these events, however, was that otolaryngology officially noticed and supported its facial plastic surgeons. Not long afterward, in 1963, Lierle took aside a prominent otolaryngologist--Joseph Goldman, who

Otolaryngology Head and Neck Surgery July 1996

was then chief of otolaryngology at Mt. Sinai Hospital; chairman of the ear, nose, and throat section of the AMA; and a political force in his own right--and advised him to organize facial plastic surgeons into one society. Future support from otolaryngology would be easier to obtain this way, he said. At the time, there were three societies--each formed by the loyal followers of Foman, Cottle, and Goldman. After much negotiation, the terms of amalgamation were agreed on. Although the Cottle society (the American Rhinologic Society) at the last minute chose to remain separate, on October 18, 1964, the Foman and Goldman groups merged into a new society named the American Academy of Facial Plastic and Reconstructive Surgery. Incorporation of the society was arranged in New Jersey by Irvin J. Fine, who would serve as the group's first treasurer. The main goals of the AAFPRS were remarkably similar to those steadfastly pursued by facial plastic surgeons since the 1920s: to continue developing training opportunities and to win recognition for their expertise. To achieve these goals, the AAFPRS had to negotiate its way through some turbulent waters. A major question was whether it would be better to work within otolaryngology, which had withheld its endorsement for so many years, or to go it alone. This question had no easy answer because otolaryngology had been undergoing its own identity crisis since the end of World War II. Certainly otolaryngology was no longer a specialty of the ears, nose, and throat. Its focus increasingly was on head and neck surgery, but the identity of otolaryngology as one specialty seemed in doubt. The field had broken into many small specialties--bronchology, esophagology, facial plastic and reconstructive surgery, head and neck surgery, laryngology, otology, rhinology, and m o r e - and every branch of the specialty had its own academic society. In the mid-1960s, the AAFPRS was one of a dozen or more otolaryngology groups, each with its subspecialty interest. None could claim to speak for one and all. The venerable AAOO had an esteemed educational presence, but the sociopolitical-economic concerns of otolaryngologists lacked leadership. Each group keenly felt the lack of a unified voice and felt that it independently had to defend the specialty' s expansion into head and neck surgery. The result was that the AAFPRS pressed forward to achieve its own goals, while simultaneously joining with the other special-interest otolaryngologic groups to sponsor a new national society that would give one voice to otolaryngology. That society, the American Council of Otolaryngology, was formed in 1968 and went through several transformations before emerging in 1982 as the present-day American Academy of Otolaryngology-Head and Neck Surgery.

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Volume 115

Number I

EDUCATION FIRST

In this climate, then, the AAFPRS proceeded to achieve the first of its two major goals, education. There was a natural give-and-take between organizations because AAFPRS and AAO-HNS members contended with issues that affected them variously. The road in particular was not always smooth between the AAFPRS and academic programs, which only gradually arrived at their support of training in facial plastic and reconstructive surgery as otolaryngology department chairs searched their own beliefs. But, if relations at times were strained, major objectives nonetheless were achieved before many years passed. Credit certainly is due early leaders, who kept the main goal before them. "We could all see that if we were going to succeed in the long range, we had to have an extremely good educational program," recalled G. Jan Beekhuis, the AAFPRS's first education chairman and its 1973 president. Jack Anderson concreted, often saying at AAFPRS board meetings that medical students interested in facial plastic surgery would not pursue otolaryngology without the dual incentive of facial plastic surgery training in residencies and postgraduate work through the AAFPRS. Progress in postgraduate training came first. The AAFPRS early on began to develop major courses not available elsewhere, and in 1969 it offered its first aging face course. The idea of teaching facial plastic surgery procedures not addressed in residency training programs was a radical idea in the mid-1960s, but the plan was to fill the gaps until facial plastic surgery procedures were included in residency curricula. In 1970 the AAFPRS applied to the AMA's Accreditation Council for Continuing Medical Education for permission to offer its courses for credit. Permission was granted, making the AAFPRS the first organization in otolaryngology to secure such approval for courses conducted in a nonuniversity setting. Meanwhile, plans proceeded to redefine the essential training for otolaryngology residencies to include not only the aging face but also all facial plastic and reconstructive surgery procedures. In 1972 William Wright (AAFPRS president in 1970) reported to the AAFPRS board of directors that efforts were proceeding to interest various universities in starting courses in head and neck reconstruction, maxillofacial trauma, and skin surgery. Soon after, Charles J. Krause (AAFPRS president in 1981) reported that the AAFPRS was continuing to work with the training programs, offering every assistance possible to upgrade programs. In the mid1970s, Charles W. Gross, then AAFPRS education chairman, urged the AAFPRS to help residencies to develop soft tissue courses, saying, "You can't do head

SIMONS a n d HILL

11

and neck surgery without doing repair of the surgical defect." Teaching the first soft tissue course was John T. Dickinson (AAFPRS president in 1965), who deserves credit for starting the AAFPRS audiovisual library. When Ted A. Cook (AAFPRS president in 1989) upgraded and expanded soft tissue courses later on, he looked back to the early 1970s and commented of that time, "Most residents became knowledgeable in soft tissue techniques through AAFPRS courses." With each refinement to residency training, a step was taken toward universal inclusion of facial plastic surgery in otolaryngology residencies. Finally, in 1975, the ABO, the AMA, and the American College of Surgeons (ACS) approved a revised Essentials in Otolaryngology, which for the first time made mandatory the inclusion of facial plastic surgery training in residency programs and the mastery of this subspecialty for ABO certification. The document was a joint effort of all related groups, although it is generally agreed that the burden of AAFPRS correspondence with the AMA and ABO fell to then AAFPRS Secretary Carl N. Patterson (AAFPRS president in 1975). Patterson, however, fully credits Jerome Hilger (AAFPRS president in 1979; AAOO president in 1970), George A. Sisson (AAFPRS president in 1978; AAO-HNS president in 1983), John Dickinson (AAFPRS president in 1965), Walter Work (ABO president from 1968 to 1972), and other members of the ABO for their help. Looking back on this period in the 1980s, M. Eugene Tardy, who headed the AAFPRS in 1982, the AAO-HNS in 1986, and the ABO in 1995, observed that: In the earliest days we sought out university programs with which to co-sponsor courses and AAFPRS programs and educational activities, and it was important for both universities and the Academy to work jointly on these things. That relationship has continued. I think that one of the most important things that has occurred as a result of this cooperation is that today, as opposed to even ten years ago, in almost every major university teaching program in this country there is a person in otolaryngology/head-and-neck surgery who has had a fellowship within the AAFPRS. The fellowship program alluded to by Tardy had been started by the AAFPRS in 1968 as a natural extension of residency training. However, it was not until 1988 that the fellowships which until 1988 operated more like preceptorships, matching postgraduates with senior surgeons with whom they wanted to study--were standardized. Standardizing training was necessary preparation to seeking accreditation for the fellowships from the AMA Accreditation Council for Graduate Medical Education, and Peter A. Adamson (AAFPRS president-

12

SIMONS and HILL

elect in 1995) volunteered for a lead role in this effort. A standard curriculum was developed, as well as an examination based on the curriculum. The examination was to be administered by a new entity, the ABFPRS, incorporated in 1986. Leading examination development activities was Donn R. Chatham, whose prodigious efforts earned him the moniker of "father of the ABFPRS examination." As this article goes to press, application has been made for accreditation by the AMA Accreditation Council for Graduate Medical Education, a process in which many recent AAFPRS presidents have participated, including Richard L. Goode (1984), Fred J. Stucker (1991), J. Regan Thomas (1992), Roger L. Crumley (1994), and Wayne F. Larrabee (1995), as well as G. Richard Holt, whose efforts have been significant for both the AAFPRS and the AAO-HNS (1992 president). RECOGNITION

NEXT

As the AAFPRS educational program took shape in the 1970s, it seemed logical to approach other medical societies for recognition. Again Carl Patterson got to work, and in 1972 the AAFPRS was seated on the new AMA Plastic Surgery Section. In 1974 a seat was secured on the ACS Board of Governors, and in 1978 representation to the AMA House of Delegates was approved. These events, together with AMA' s inclusion in 1985 of the term facial plastic surgery on its physician self-designation list, substantiated the national recognition of facial plastic surgery within the otolaryngology specialty. All of this recognition did not sway the general plastic surgeons, who continued to denigrate the facial plastic surgery training of otolaryngologists. A critical point came in 1980, when Jack Anderson wrote an article explaining how otolaryngology had evolved into a head and neck specialty. Titled "An Old Medical Specialty Puts on a New F a c e . . . and H e a d . . . and Neck," Anderson' s article was summarized and reprinted in the Journal of the Medical Association of Georgia, jointly bylined by Anderson and William E. Silver. It incensed two general plastic surgeons, who in turn published an article titled "Things Are Never What They S e e m - Skim Milk Masquerades a s Cream." Anderson sued, and when he won $1.5 million on appeal in 1988, he donated the proceeds to the Educational and Research Foundation for the AAFPRS. In accepting the gift, then AAFPRS President John R. Hilger said, "No one stands taller in the ranks of facial plastic surgery than Dr. Anderson, and his gift demonstrates the high principles he has set for facial plastic surgery." Anderson's gift endowed the fellowship examination administered by the ABFPRS.

Otolaryngology Head and Neck Surgery July 1996

(The AAFPRS Foundation, established in 1972, had attracted little monetary support until 1966 AAFPRS President John J. Conley, in response to the 1985 inaugural address of incoming AAFPRS President Robert L. Simons, sent a check for $100,000. The gift prompted Simons and Howard W. Smith, who had served as AAFPRS president in 1983, to establish the Founders Club to generate additional support. Within the year, Leslie Bernstein, who had served as AAFPRS president in 1977, contributed $250,000 for research. Smith himself gave generously, as did 1986 AAFPRS President E. Gaylon McColl0ugh, and soon other leaders followed suit. Today the endowment sustains not only educational but also humanitarian programs, such as the international Face-to-Face program and its companion National Domestic Violence Project.) As Anderson's suit was winding down in court, the AAFPRS also approached the ABO, seeking that august body's support before the ABMS for some form of ABMS subspecialty recognition in facial plastic surgery. It was important for AAFPRS members to be able to identify themselves as "board-certified facial plastic surgeons" so that the public had a few plain English words by which to recognize surgeons' essential facial plastic surgery training. This need was underscored by yet another public campaign conducted by the general plastic surgeons, who encouraged patients to see only a "board-certified plastic surgeon" and misinformed the public that the ABPS was the only ABMS board that certified in plastic surgery. What the AAFPRS proposed to the ABO in 1987 was that the ABO spell out on its certificate the five types of training required of ABO diplomates, including facial plastic and reconstructive surgery. Under pressure from the ABPS and others, the ABMS filed an injunction, preventing this simple compromise. Summarily dismissed by the ABMS in informal conversations was the option of a certificate of added qualifications in facial plastic surgery. The ABO was told it need not bother to apply for this pathway to subspecialty certification because "plastic surgery" was already the domain of a primary board, which arguably occupied it completely. As the AAFPRS explored and exhausted all traditional means of achieving subcertification, it reached the conclusion that--once again, at least for a while--it should proceed independently. The mechanism for subcertification chosen by AAFPRS leaders was the ABFPRS, which had been examining only surgeons completing AAFPRS Foundation fellowships since the ABFPRS's incorporation in 1986. In 1989 it was decided to expand the ABFPRS examination process to a full-fledged credentialing process to certify postresidency surgeons in facial plastic and reconstructive sur-

Otolaryngology Head and Neck Surgery Volume 115 Number I

gery. In 1991 the ABFPRS awarded its first certificates and, in 1992 it became independent from the AAFPRS, moving into its own headquarters office within the AAO-HNS building. The obvious determination of facial plastic surgeons to achieve subspecialty recognition caused the general plastic surgeons to seek a final battlefield for their turf war. In the late 1980s, they asked the Federal Trade Commission to rule that physicians must disclose their certifying board when they identify themselves as board certified. W h e n the Federal Trade Commission declined, they launched a campaign to encourage state legislatures to pass laws that would permit physicians to disclose only ABMS or equivalent board certification. In every state that passed such restrictive legislation, the ABFPRS has since been recognized as equivalent to A B M S primary boards. In effect, the campaign to illegitimize the ABFPRS only succeeded in providing the opportunity to prove its valid and legitimate existence. With the increasing universal recognition of the ABFPRS and the heightened activities within the otolaryngology residency programs, the time has come to solidify the position of our subspecialty. CONCLUSION

Facial plastic surgery has generated interest and excitement since the earliest days, when pioneering surgeons began to explore this new frontier. There has been great opportunity to learn and then teach, to formalize training opportunities, and to extend the boundaries of basic principles long taught within otolaryngology residencies. Further, the opportunity for basic and clinical research in facial plastic surgery has grown substantially during the past 15 years. Today, research reports share the spotlight with lasers, endoscopes, free-flap reconstructions, and other technologic and scientific advancements. At times, progress in these areas occurred within the otolaryngology family, and other times it occurred independently. We seem today to be at a watershed, with training established and recognition secure. It is time to move on to the more pressing issues of the d a y - - t o restore patient confidence, to continue the advancement of techniques to improve patient treatment, and to negotiate our way through this new managed care landscape in a way that preserves our ability to provide the care we have devoted ourselves to deliver. These goals will be most easily accomplished and securely established by harnessing our impressive energies. Today's needs and yesterday's lessons dictate that appropriate action demands the collaborative effort of the ABO, AAO-HNS, AAFPRS, and ABFPRS. A new day in a unified under-

SIMONS and HILL 13

standing and support for facial plastic surgery augurs well for the future strength of our specialty and for the welfare of patients seeking our expertise. BIBLIOGRAPHY

Anderson JR. An old medical specialty puts on a new face.., and head.., and neck. South Med J 1980;73:1058-62. Bordley JE. The history of the AmericanCouncil of Otolaryngology 1968-1981. Alexandria,Va.:AmericanAcademy of OtolaryngotogyHead and Neck Surgery Foundation,Inc, 1993. McDowel E Silvergirl's surgery.ArlingtonHeights, Ill.: Educational Foundation of the American Society of Plastic and Reconstructive Surgery, 1975. Natvig R Jacques Joseph: surgical sculptor. Philadelphia, Pa.: WB Sannders, 1982. Rusca JA, HugerWE Jr. Thingsare neverwhat they seem--skim milk masquerades as cream. J Med Assoc Ga 1982;71:103-5. Simons RL, ed. Comingof age: a twenty-fifthanniversaryhistory of the AmericanAcademy of Facial Plastic and ReconstructiveSurgery. New York: Thieme Medical PublishersInc., 1989. Simons RL. From the ABFPRS view: the issues of subspecialization and certification.AAO-HNS Bulletin 1993;12:120. A P P E N D I X 1: C H R O N O L O G Y OF SUBSPECIALTY DEVELOPMENT

1964 AAFPRS officiallyfounded October 18, 1964 1968 AAFPRS fellowship program begun * AAFPRS audiovisual library started 1969 AAFPRS aging face course begun • AAFPRS soft tissue workshops begun 1970 First InternationalSymposiumin New York * AAFPRS published firstpatientbrochure, "Facts aboutPlastic Surgeryof the Nose" • AAFPRSbecamefirstnonuniversitygroup in otolaryngologyto get AMA approval to grant ContinuingMedical Education credit 1972 One thousandAAFPRS members • AAFPRSEducationaland Research Foundation established • AAFPRS seated on new AMA Plastic Surgery Section 1974 AAFPRS secured seat on ACS Board of Governors 1975 Second InternationalSymposiumheld in Chicago, Illinois ABO, ACS, and AMA approved Essentials in Otolaryngology 1976 AAFPRSSan Diego Classics videotapeseriesbegun • AAFPRS Learning Center exhibitedfor first time in Palm Beach, Florida 1978 AAFPRS representationto AMA House of Delegates approved 1979 Third InternationalSymposium,New Orleans, Louisiana 1980 AAFPRSvideotape librarymoved to San Diego • Jack Anderson published"An Old Medical SpecialtyPuts on a New Face... and Head... and Neck" in the Southern Medical Journal 1981 "Delineationof"Hospital Privilegesfor the Practice of Head and Neck Surgery" published by AAFPRS and AAO-HNS * Facial Plastic Times began publication 1982 AAFPRS office moved to Washington,D.C. • Lawsuit filed in Georgia alleging libel and defamationof character 1983 Lee VanBremen hired as first full-time AAFPRS executive vice-president • 2000 AAFPRSmembers • AAFPRSbecame member of AccreditationAssociationforAmbulatoryHealthCare • Fourth InternationalSymposiumheld in Los Angeles 1984 AAFPRS published first monograph: Proportions of the Aesthetic Face, by Powell and Humphrey

14

Otolaryngology Head and Neck Surgery July 1996

SIMONSand HILL

1985 John Conley endowed AAFPRS Foundation with first sizeable gift • Term facial plastic surgery approved in AMA self-designation list

M. Eugene Tardy, MD

1982

Howard W. Smith, MD, DMD

1983

Richard L. Goode, MD

1984

1986 ABFPRS incorporated • AAFPRS Founders Club created • Georgia lawsuit tried

Robert L. Simons, MD

1985

E. Gaylon McCollough, MD

1986

1987 AAFPRS patient newsletter, Facial Plastic Surgery Today, begun • Leslie Bemstein endowed research grants with second sizeable gift to AAFPRS Foundation • Monthly publication of Facial Plastic Times began

John R. Hilger, MD

1987

Frank M. Kamer, MD

1988

Ted A. Cook, MD

1989

Norman J. Pastorek, MD

1990

Fred J. Stucker, MD

1991

J. Regan Thomas, MD

1992

H. George Brennan, MD

1993

Roger L. Crumley, MD

1994

Wayne E Larrabee, MD

1995

1991 First ABFPRS certificate awarded

Peter A. Adamson, MD

1996

1992 ABFPRS moved to independent headquarters in AAO-HNS building • T. Susan Hill hired as first full-time ABFPRS executive director • International Face-to-Face program established by AAFPRS Foundation

Secretaries

1988 The Face Book published by AAFPRS • Pages for facial plastic surgery set aside in Archives of Otolaryngology • AAFPRS fellowship program modified; first examinations given • 3000 AAFPRS members • Anderson donated proceeds from Georgia lawsuit 1989 Fifth International Symposium/celebration of AAFPRS twentyfifth anniversary, Toronto, Canada • First ABFPRS examination for certification

1993 Sixth International Symposium, San Francisco 1994 National Domestic Violence Project established by AAFPRS Foundation 1995 ABFPRS ruled equivalent to ABMS primary boards in California, after similar decisions in Florida, Colorado, and Oklahoma • 300th ABFPRS diplomate named.

Jack R. Anderson, MD t

1964-1969

Carl N. Patterson, MD

1969-1974

M. Eugene Tardy, MD

1974-1979

E. Gaylon McCollough, MD

1979-1984

Ted A. Cook, MD

1984-1989

William H. Beeson, MD

1989-1993

Stephen W. Perkins, MD

1993-1997

Treasurers Irvin J. Fine, MD

1964-1969

A P P E N D I X 2: AAFPRS OFFICERS

Samuel Bloom, MD

1969-1974

Presidents

Jack Kerth, MD

1974-1979

Irving B. Goldman, MD ?

1964

Robert L. Simons, MD

1979-1984

John T. Dickinson, MD ~

1965

Roger L. Crumley, MD

1984-1988

John J. Conley, MD

1966

David E. Schuller, MD

1988-1992

Richard T. Farrior, MD

1967

Devinder S. Mangat, MD

1992-1995

Morey L. Parkes, MD

1968

Russell W. H. Kridel, MD

1995-1998

Ira Tresley, MD t

1969

William K. Wright, MD

1970

A P P E N D I X 3: ABFPRS OFFICERS

Jack R. Anderson, MD ?

1971

Presidents

Walter E. Berman, MD

1972

E. Gaylon McCollough, MD

1973

Robert L. Simons, MD

1991-/994

Trent W. Smith, MD

1974

J. Regan Thomas, MD

1994-present

Carl N. Patterson, MD

1975

Secretaries

Richard C. Webster, MD "~

1976

Robert L. Simons, MD

1988-1991

Leslie Bernstein, MD, DDS

1977

Peter A. Adamson, MD

1991-I994

George A. Sisson, MD

1978

Fred J. Stucker, MD

Jerome A. Hilger, MD

1979

Treasurers

Sidney S. Feuerstein, MD

1980

John R. Hilger, MD

1981

Howard W. Smith, MD, DMD

G. Jan Beekhuis, MD

Charles J. Krause, MD

Peter A. Adamson, MD )Deceased.

1988-1991

1994-present 1988-1991 1991-1994 1994-present