ORIGINAL ARTICLE

The Whole Is More Than the Sum of Its Parts: Aristotle, Metaphysical Joseph Upton, MD,* Ivo Janeka, MD,Þ and Nalton Ferraro, MD* Abstract: This phrase, a favorite of Dr. Joseph E. Murray, can be interpreted in many ways. Mathematically, the whole is equal to the sum of its parts, neither more nor less. Psychological Gestalt theory would maintain that the whole is something else or something different than the sum of its parts. Merely adding up the component parts is meaningless compared with the ‘‘part-whole’’ relationship (SYNERGETICS: Explorations of Thinking. MacMillan Publishing Co, Inc; 1975). Organizational pundits maintain that this principle describes the synergy, which exists between individuals working together in a cooperative effort. Collectively, they are able to achieve an outcome superior to that of 1 or 2 people working alone. This concept is vintage Joseph E. Murray. He was an integral part of the Peter Bent Brigham team, which transformed the dream of organ transplantation into clinical reality over 50 years ago. Although many advances in medicine are made by the serendipity of a prepared mind making a critical observation (Alexander Fleming and penicillin), individual brilliance (Judah Folkman and angiogenesis), or by technology (magnetic resonance imaging), most are achieved by groups of physicians and scientists working together. All have prepared minds. When the Peter Bent Brigham Hospital physicians and researchers at the Harvard Medical School dedicated all of their energy on solving the problems of end-stage renal disease, their effort was concentrated and primarily regional. Today, this cooperation is global, as communication has been facilitated by the Internet, iPhone, iPad, video conferencing, electronic libraries, and the like. Key Words: Dr. Murray, Aristotle, metaphysical (J Craniofac Surg 2014;25: 59Y63)

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his phrase, a favorite of Dr. Joseph E. Murray (JEM), can be interpreted in many ways. Mathematically, the whole is equal to the sum of its parts, neither more nor less. Psychological Gestalt 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.

From the Department of *Plastic and Oral Surgery and †Otorhinolaryngology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts. Received August 9, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Joseph Upton, MD, Department of Plastic and Oral Surgery, Boston Children’s Hospital, Harvard Medical School, 830 Boylston Street, Suite 212, Chestnut Hill, MA 02467; E-mail: [email protected]; [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000369

The Journal of Craniofacial Surgery

theory would maintain that the whole is something else or something different than the sum of its parts. Merely adding up the component parts is meaningless compared with the ‘‘part-whole’’ relationship.1 Organizational pundits maintain that this principle describes the synergy, which exists between individuals working together in a cooperative effort. Collectively, they are able to achieve an outcome superior to that of one or 2 people working alone. This concept is vintage JEM. He was an integral part of the Peter Bent Brigham team, which transformed the dream of organ transplantation into clinical reality over 50 years ago. Although many advances in medicine are made by the serendipity of a prepared mind making a critical observation (Alexander Fleming and penicillin), individual brilliance (Judah Folkman and angiogenesis), or by technology (magnetic resonance imaging), most are achieved by groups of physicians and scientists working together. All have prepared minds. When the Peter Bent Brigham Hospital physicians and researchers at the Harvard Medical School dedicated all of their energy on solving the problems of end-stage renal disease, their effort was concentrated and primarily regional. Today, this cooperation is global, as communication has been facilitated by the Internet, iPhone, iPad, video conferencing, electronic libraries, and the like. Every year, I deliver a popular lecture to the students and house staff titled: ‘‘What is your surgical IQ?’’ In this talk, the characteristics, responsibility, intelligence, cooperation, compassion, persistence, critical eye, ability, curiosity, courage, and instinct are presented. Each is illustrated with an individual clinician who best demonstrates each trait. I could envision no better person than JEM for cooperation of a multidisciplinary team. He was a very organized individual and had a distinct vision for his new division of plastic surgery within the Departments of Surgery at both the Peter Bent Brigham and Boston Children’s Hospitals. Astutely, he merged plastic surgery and oral/maxillofacial surgery into a single division and had the strong support of the chief of surgery at both hospitals. Three physicians were recruited to fill 3 specific job descriptions: John B. Mulliken as a pediatric plastic surgeon, Leonard B. Kaban as an oral maxillofacial surgeon, and Joseph Upton as a hand and microvascular surgeon. He did not fill these 3 positions at once and waited until he found the right person for each job. Although all 3 practices of his junior attending surgeons were heading in different directions, we constantly worked synergistically on common patients. We made rounds, operated, attended conferences in both hospitals and craniofacial review sessions, and ran clinics and symposia together. Interesting cases were always shared, and there were very few clinical problems, which were unwilling to accept. All 4 of us shared the curiosity, tenacity, and hard-work genes. Weekends were frequently part of our normal work week. The cross fertilization between areas of expertise and academic productivity was dramatic. The area in which we worked most commonly was the craniofacial clinic and later the vascular anomalies center. He let us follow our interests and passions and encouraged innovation, hard work, and creativity. As our chief, he did not try to mold us into the clinician/ scientist JEM. He always knew that working together we would always achieve more than we would have accomplished alone. In Surgery of the Soul: Reflections on a Curious Career,2 JEM chronicles his life in medicine and punctuates his own story with the

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case histories of 14 of his memorable patients. I remember 4 of them very well. Each had a complicated medical problem with no easy solution. Each had a family and life, which had been dramatically altered by their medical condition. Each had the courage to endure the surgical solution. Each persisted as long as possible. Most had long, fulfilling lives. Another favorite JEM phrase was Churchill’s exhortation: ‘‘Difficulties made are opportunities won.’’ He enthusiastically envisioned difficult medical problems as opportunities to be creative, learn, persist, and contribute. This philosophy and his approach to patients pervaded in the craniofacial clinic where we treated many patients through 2 to 3 decades of their lives. When the glass was always ‘‘half full,’’ boundless opportunities are available to our patients. Optimism always helped us get through difficult times; JEM had an overabundance of this trait.

CASE PRESENTATION At age 3 years, biopsy of a right tonsillar mass in a young Hasidic revealed a diagnosis of rhabdomyosarcoma. A 1-year course of chemotherapy and full course of radiation therapy followed. He was symptom-free for 4 years. At age 8 years, the mass reappeared and was hard, ulcerated, and adherent to the mandible. This time, surgical extirpation was recommended. Over the next 15 years, he would have a number of surgical procedures first to eradicate his malignancy and then to reconstruct the ravages of surgery and the effects of radiation therapy and chemotherapy upon growth. He had a total of 4 free-tissue transfers, all of which involved either a new flap at the time or a unique

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application of a previously described flap. They operative procedures are summarized as follows: (1) age 3 years: diagnosis, rhabdomyosarcoma; full course of radiation therapy and 1 year of chemotherapy (2) age 8 years: excision of tumor right cranial base and infratemporal fossa with hemimandibulectomy and partial maxillectomy; free latissimus dorsi myocutaneous flap with skin paddles to line nasal and oral cavities; primary microscopic repair (no. 2 branches) or sural nerve graft (no. 2 branches) to individual branches of the seventh nerve (3) age 12 years: insertion of custom polyethylene implants to right temporal, zygomatic, and cheek regions; removed 6 months following exposure within irradiated tissue and subsequent infection (4) age 15 years: hemimandibular reconstruction with a fibular osteofasciocutaneous flap; local fascial flap interposition for new temporomandibular joint (5) age 17 years: augmentation of right side of face with a free scapular/ parascapular fat-fascial flap; augmentation of upper and lower lips with tongues of vascularized fascial tissue from flap (6) age 18 years: excision of skeletal ankylosis between the fibular graft and the cranial base and interposition of vascularized tissue from a free radial forearm flap; radial forearm flap for resurfacing following release of submandibular contracture; brow lift; correction of ectropion; chin augmentation with polyethylene implant (7) age 18 years: decision not to place osteointegrated implants on right because he had good occlusion and function on the left and no

FIGURE 1. Appearance at 8 years. T2-weighted magnetic resonance imaging shows irregular, homogeneous mass in the right maxilla with extension to the cranial base. Facial atrophy and diminished skeletal growth from irradiation are becoming evident. En bloc resection included hemimandible, a portion of maxilla, and overlying soft tissue with preservation of skin flaps.

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

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Whole Is More Than the Sum of Parts

FIGURE 2. Appearance at 15 years. Both soft tissue and skeletal defects are evident. A segmented free fibular osteofasciocutaneous flap was used for correction of both. This composite flap included bone, fat/fascia, full-thickness skin, and muscle.

FIGURE 3. Appearance at 17 years. With further growth, a major soft tissue deficit is still present. A scapular/parascapular flap with a long pedicle has been transferred to augment soft tissue. Recipient vessels are in the lower neck region.

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FIGURE 4. Appearance at 18 years. Because dental occlusion and teeth on the left side were satisfactory, a decision was made not to place osteointegrated implants on right. Fibular graft has fused to cranial base and was resected. A radial forearm fasciocutaneous flap with long pedicle was used to fill the submandibular contracture release defect. The most distal portion is used as an interposition for the new TMJ. Soft tissue symmetry has been improved with further fat grafting.

maxillary teeth or bone for occlusion on the right; single-barrel fibular not enough bone stock for implants (8) age 19 years: excision of epithelial sinus beneath cranial base (9) age 20 years: fat injection for soft tissue asymmetry along and mandibular bodies; revision of malar and chin implants (10) age 21 years: repeat fat injections to the right cheek and nasal regions; alloderm implantation into the upper lip; scar revisions (11) age 22 years: marriage (12) age 23 years: 1 child During this surgical odyssey, he became well known to all in the craniofacial clinic and actually through his persistence achieved an excellent functional and aesthetic result. His parents and 9 siblings have remained very supportive during this time of his life.

DISCUSSION We learned more from him than we actually gave to him. His surgical history documents many important lessons in the treatment of infratemporal malignancies and the reconstruction of massive defects in the head and neck region. (1) Vascularized tissue. Before this case, malignancies in this region were treated only from below the cranial base, and cerebrospinal fluid leaks and subsequent infections were common. With unlimited amounts of vascularized tissue available, we could now also approach these tumors from the cranial side, seal possible open leaks with healthy muscle, and design epithelial lined surfaces to line the nasal and oral cavities. Although this may sound intuitive

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FIGURE 5. Appearance at 21 years. Symmetry has been improved following revision genioplasty, autogenous fat injections, and lip augmentation. Persistent ectropion did not bother the patient.

* 2014 Mutaz B. Habal, MD

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FIGURE 6. Appearance at nuptials. A proud patient presents his beautiful wife and elegant shtreimel.

now, it was a big step 30 years ago (Fig. 1). This represented a giant leap from our treatment of one of JEMs patients, Frank Wint, who of died of intracranial extension of his cranial base malignancy. (2) Fibular segments. Next, we learned that and fibular could be divided into many segments as long as periosteum and nutrient vessels were present within each segment. Numerous cutaneous segments could also be harvested with this flap without much morbidity to the leg (Fig. 2). The small cutaneous perforators were always visible along the intermuscular fascial planes. In addition, this tissue was quite thin and easily separated into individual segments. We did not expect the fibular fusion to the cranial base but in retrospect should have expected this outcome. (3) Scapular/parascapular flap. After performing a number of dissections in the cadaver laboratory, we realized that the scapular/ parascapular flap could also be divided into individual parts as long as each contained an axial vessel. In addition, the major transverse scapular vessels could be followed deep within the axillary space where their diameters were quite large (Fig. 3). Retraction and good hemostasis were the key. In this patient, we had 4 separate parts of the flap. With preservation of the skin on the back, we did not need to deal with the problems incurred by placing a skin graft over the mobile scapula. Osteointegrated implants had been described, and here we learned that a large amount of vascularized bone are needed for successful integration. The double-barreled fibula helped provide more bone stock where needed. (4) Submandibular contracture. The soft tissue deficiency in the submandibular region in growing children and adolescents is another persistent problem, which has not been addressed in the literature in the past. Because these reconstructed fibular mandibles

Whole Is More Than the Sum of Parts

do not grow, they require advancement, which cannot be performed without adequate soft tissue. Following irradiation, local tissues are usually not available, and the best solution is a free tissue fasciocutaneous transfer. Although the radial forearm flap in this patient was not very wide, it did make a tremendous difference to the patient, who can now extend his neck fully and gaze upward without moving his body (Fig. 4). (5) Recipient vessels. Several important lessons were re-enforced during this reconstruction, which included 4 separate free flaps. The first was that it is possible to use irradiated recipient vessels. The dissection is difficult; the veins in particular can be easily damaged. The second is the need for strategic planning when more than 1 flap is needed. Although the lower neck was not irradiated, it was heavily scarred. During the initial resection, we did not violate the neck and used large vessels within the operative field, in this case the superficial temporal artery and vein, which matched the flap vessels very well. For the next transfer, more caudal vessels (ie, facial artery and external jugular) were used, and with subsequent flaps, we moved more caudal to the superior and inferior thyroid artery levels and finally end-to-side into the carotid. With each flap, we avoided as much dissection into regions we would need in the future. Optional strategies would have been to use vein grafts or arteriovenous loops from the contralateral side. (6) Fat grafting. During the past 8 to 10 years, our cosmetic colleagues have refined the techniques of fat grafting. We used these techniques to augment soft tissue asymmetry in the buccal regions and along the sides of the mandible (Fig. 5). With this patient and several others, we learned that the zygoma and chin are 2 areas that cannot be augmented permanently with soft tissue alone and that solid implants, either autogenous bone or Medpore, were better options. By this time, JEM had retired. Before that time, he eschewed with use of any alloplastic material. And we were strongly encouraged not to use them. (7) Hair growth. Finally, an interesting observation was made that may or may not be of significance. The dissection and injection of fat within the irradiated cheek tissue and along the sides of the mandible enhanced the growth of his beard, which within his culture is very important.

CONCLUSIONS Despite the difficulties imposed by a malignant tumor and 2 decades of reconstruction, this patient has exhibited great patience and persistence and has set high standards for all of his doctors. He is now married and has started his own family with a baby daughter and works within the family business (Fig. 6). A most gracious and grateful man, he and his family have helped us both introduce and refine many facets of reconstructive microsurgery at a time when none of these procedures were being performed. Lessons learned have helped contribute to the well-being of subsequent generations of patients with similar problems. Our collective team has been able to give him more than any of us could have accomplished alone. This whole has been greater than the sum of its parts. A notable legacy for a notable person, JEM.

REFERENCES 1. Fuller RB, Applewhite EJ. SYNERGETICS: Explorations of Thinking. Boston, MA: MacMillan Publishing Co, Inc; 1975 2. Murray JE. Surgery of the Soul: Reflections on a Curious Career. Canton, MA: Science History Publications/USA, Boston Medical Library; 2001

* 2014 Mutaz B. Habal, MD

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

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The whole is more than the sum of its parts: Aristotle, metaphysical.

This phrase, a favorite of Dr. Joseph E. Murray, can be interpreted in many ways. Mathematically, the whole is equal to the sum of its parts, neither ...
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