SPECIAL EDITORIAL

Craniofacial Surgery: The First 25 Years. Where Do We Come From? Who Are We? Where Are We Going? Mimis Cohen, MD, FACS

FIGURE 1. Paul Gaugin painting entitled ‘‘Where Do We Come From? What Are We? Where Are We Going?’’ Reprinted with permission from The Museum of Fine Arts, Boston, MA.

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aul Gaugin, the famous French painter, attempted to answer these eternal questions in his beautiful painting with the same title. This masterpiece is now in the Museum of Fine Arts in Boston. The painting should be read from right to left and represents the cycle of life from birth to old age with many allegoric and cryptic messages and symbols (Fig. 1). The Journal of Craniofacial Surgery will be celebrating in 2014, 25 years of continuous and successful publication. Such milestone definitely calls for celebrations but also for reflection on the long road it covered, the present situation, and the vision for the future. I chose to borrow the title from Gaugin’s painting to follow the steps of the journal and craniofacial surgery for this editorial. The Journal followed closely the advances of craniofacial surgery over the last quarter of a century and published over the years pioneer and cutting-edge articles by top contributors in the field from the United States and from around the world. As the newborn baby at the bottom right of Gaugin’s painting, the new journal started with a modest number of 370 pages a year in a quarterly format. Dr Mutaz Habal, the editor-in-chief, summarized the goals of the What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.

Received September 16, 2013. Accepted for publication October 21, 2013. The author reports no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000479

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new publication in his first editorial envisioning it to become a multidisciplinary forum by accepting clinical and research contributions from all related surgical, medical, and paramedical specialties. The late Robert Goldwyn in his forward eloquently supported the need for the new journal stressing the unique concept of team approach for craniofacial surgery and therefore the need for interaction of many specialists to provide optimal care for the patient. Topics of the first issue included among others: intracranial volume in children with craniosynostosis, oblique craniofacial clefts in children, fibrin glue in craniofacial surgery, and indications for use of a microsystem for internal fixation in craniofacial surgery. As in the middle grouping of Gaugin’s painting, the journal matured and expanded quickly following closely and supporting progress as well as all new ideas and concepts in the field. Many refinements of existing surgical techniques for bony and soft tissue reconstruction were presented, new concepts evolved, and technological advances in imaging and computer-assisted evaluation and planning were introduced. Tessier, Obwegeser, and several other pioneers firmly established the principles involved in disassembling and reassembling of the craniofacial skeleton including safe transcutaneous/transoral approaches, carefully designed osteotomies, rigid skeletal fixation systems, and the liberal use of bone grafts. The surgical advances of the past quarter of a century and in the years to come will primarily represent additional refinements based on these core principles. These refinements in craniofacial surgery included among others skeletal distraction osteogenesis, nasoalveolar molding, and preoperative orthopedics for patients with clefts, endoscopic approaches to the cranial vault and the facial skeleton, alloplastic and cellular-based tissue engineering for bone and soft tissue substitutes, osseointegrated implants for dental rehabilitation and retention of craniofacial prosthesis, and improvements in soft tissue reconstruction. Most notably the era

The Journal of Craniofacial Surgery

& Volume 25, Number 1, January 2014

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 25, Number 1, January 2014

of facial transplantation has now become a reality and added to our armamentarium. As our surgical experience grew, our ability for multidimensional visualization of the anatomy improved with the technological advances in imagining that included increasing resolution in computed tomography, magnetic resonance imaging, and positron emission tomography. As the scan acquisition was isotropic or nearisotropic resolution, the images did not need to be restricted to the conventional axial images. Thus, it became possible to build threedimensional volume by ‘‘stacking’’ the individual two-dimensional slices and to fuse the various imaging acquisition modalities by coregistering the data sets. The internal three-dimensional anatomy could now for the first time be visualized. Three-dimensional solid models of the craniofacial skeleton could be printed using standard industry applications of the computer-aided design and computeraided manufacturing technology. Thus, the surgeon has the ability not only to visualize the three-dimensional CT anatomy, but also to hold a replica of the patient’s craniofacial skeleton in his/her hands and rehearse the surgery as true model surgery. These advances make even more remarkable the outcomes that Tessier and others achieved in an era when visualization of the craniofacial skeleton was based on conventional film radiographs that required a remarkable degree of imagination for interpretation. We now have the ability to fully visualize the complexity of a deformity and the possibility to manipulate those data so that surgery could be simulated in a three-dimensional virtual space. The technological promise of the future is that various surgical options will be tried out ex vivo to optimize the outcome. The surgical steps will be well defined, and the operating room will not be a place of trial and error but rather a place for precise execution of a well-thought-out architect’s blueprint. Such technology will not only benefit surgeons but will also have a significant impact on the education of trainees, because the introduction of haptic technology to a virtual craniofacial skeleton will provide them with critical tactile feedback. Osteotomes and reciprocating saws not only will be virtually simulated visually, but also be given a sense of touch as a solid object to truly simulate the surgical experience. Moreover, in an increasing digital era and access to the World Wide Web, surgical libraries of clinical cases will become available. Conventional surgical atlases in which three-dimensional images are rendered on two-dimensional pages by artists will be replaced by a virtual library of real patient cases. The residents will be able to manipulate in three-dimensional space to better understand the anatomy and various surgical options and rehearse the procedure not in an anatomy laboratory on a ‘‘generic’’ skull specimen, but on the patient’s ‘‘skull’’ in a simulation laboratory, which will be their own laptop. Within this same time frame, our understanding of the morphogenesis of craniofacial malformations tremendously changed through the efforts of developmental biologists, geneticists, and tissue engineers. The cross-discipline of classic morphology and molecular biology, ‘‘molecular morphology’’ today, provides the basis of our understanding of the evolutionary changes in the formation of the head as an organ and in turn begins to clarify the developmental mechanisms that result in craniofacial malformations. The genetic code for the various craniofacial syndromes that were until recently diagnosed only by clinical signs was unraveled. Animal models and organ cultures were established allowing manipulation of the normal sutural fusion process through various modulators. These findings opened the possibility of future in utero manipulation. For the first time, the potential for medical management either as replacement or as an adjunct to a surgical manipulation of the craniofacial deformity seems to become feasible. Animal models have been crucial to these advances in our understanding of normal morphologic development, cellular move-

Special Editorial

ment, cell signaling, gene interaction, and transcriptional regulation in spatial patterning with unfolding in the fourth dimension of time. By the end of the 20th century, the various craniofacial conditions previously identified only by physical findings were now becoming unraveled through a genetic basis with advances in DNA technology (recombinant, polymerase chain reaction, sequencing, and linkage analysis and candidate analysis techniques). For example, in the group of autosomal-dominant craniosynostosis syndromes, mutations affecting the genes that code for the transmembrane tyrosine kinase receptor family of fibroblast growth factor receptors were identified. These findings in humans were supported by the immunohistochemical and in situ studies in mice showing the expression of fibroblast growth factor receptor in regions of developing cranial and facial sutures. Such studies hold the promise toward future treatment strategies in craniosynostosis that someday may include regulating fibroblast growth factor activity either through the ligand-receptor activation at the cellular membrane level or through the use of intracellular signaling inhibitors. Thus, what was once imprecise clinical pattern recognition and skeletal carpentry will in time with advances in molecular genetics add precision to our understanding of the role of the genes that determine the fate between normal and abnormal craniofacial development. With that understanding holds the future possibility of replacing macroscopic surgery of the previous century by molecular surgery for the century to come. The craniofacial surgeon will no longer be a surgical technician, but become a physician in its truest sense. To include this extensive body of knowledge but also present in detail issues related to ethics, safety, and policy, among others, and to disseminate the information in a timely fashion, the pages of the journal were gradually increased to more than 2000 a year with 6 issues, a supplement, and e-publication. Availability is now possible for direct view in various electronic media and direct translation into Mandarin. One might ask if having achieved so much there are more room to expand and if yes where will we be going in the future? Although we do not pose a crystal ball and cannot expect enlightenment by the blue idol in Gaugin’s painting supposedly representing the ‘‘unknown future,’’ we can make some safe predictions: navigational surgery guided by virtual surgical planning will become the standard of care for many surgical procedures resulting to more accurate execution with better results and reduction of the surgical time; minimally invasive and robotic surgery will play a bigger role and be used in several of our procedures while further refinements in facial transplantation will allow us to solve soft tissue problems that could not be adequately addressed in the past. Biologically engineered materials will be widely available as alternatives to the autogenous bone grafts, whereas mesenchymal stem cells and adipose-derived stromal cells could become part of our daily practice for reconstruction of the skeletal framework and overlying volumetric soft tissue deficit. Genetic manipulations of the primary pathology might result in a significant reduction, if not elimination, of some congenital craniofacial anomalies, and progresses in oncology might result in reduction of head and neck tumors. Above all, it is also quite certain that human ingenuity will continue advancing existing knowledge and successfully test and explore other areas currently unknown to us. In addition to direct patient management, we are facing and will face in the future multiple challenges related to the ever evolving health care regulations; the growing control and power that the government, insurance companies, and hospitals are gaining over the practicing physicians; decreased reimbursement; decreased funds for research; and encroachment by other specialists. This by no means will result to the end of the specialty. In the contrary, the future of craniofacial surgery is not bleak or uncertain, as in Gauguin’s painting. Despite all the challenges, we

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Special Editorial

The Journal of Craniofacial Surgery

cannot and should not lose hope. We need to remain our patients’ stronger advocates and continue aiming for constant improvements in safe, ethical, and cost-effective patient care with the understanding that reconstructive surgery is and will remain an integral part of our tradition and our specialty. The Journal of Craniofacial Surgery had a tremendous success over the last quarter of a century providing an important forum to

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& Volume 25, Number 1, January 2014

all practitioners around the globe interested in this topic. With this established tradition, the support of the publisher, the hardworking editorial board, and the loyal contributors and readers, it is reasonable to believe that the future is bright and that the journal is here to stay for the years to come as an important forum for dissemination of knowledge and an educational pillar in plastic surgery.

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Craniofacial surgery: the first 25 years. Where do we come from? Who are we? Where are we going?

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