Leaders in Plastic Surgery

Hand Surgery

Up to 1974, Bill Grabb, John Tipton (until 1969), and I managed the majority of soft tissue injuries of the hand and forearm at SJMH. Most of the hand trauma in that period at the UM was taken care of on the orthopedic service unless directly referred to plastic surgery. A lot of upper extremity tendon and nerve injuries, as well as some quite serious soft tissue trauma and burns, came under our care, which nicely augmented the experience our residents were having on the Detroit Hand Service rotation. In 1967, ROD, WCG, and I published in the Michigan State medical journal, an update on current use of flexor tendon grafts.[25] Later, because of the common postgraft tendon adhesion that occurred in the more complex injuries and limited tendon excursion, we began to use, in badly traumatized injuries, the “Hunter silicone rod” technique. These rods were placed into the palm and fingers to stimulate a new tendon sheath with less chance of forming adhesions after the tendon graft was placed in a secondary procedure.

At SJMH, we usually collaborated with orthopedic consultants when there were associated bony injuries. They were happy to share in the tendon repair work after there was an accidental medial nerve stripping on their service in an attempt to procure a palmaris longus graft. One of the cases I did early in my practice illustrated the principle of sharing part of a nonfunctional digit to restore function in an essential digit. The patient had a partial amputation of his dominant thumb just distal to the M-P joint and of his adjacent index finger through the mid-proximal phalanx. This injury resulted in a nonfunctional, too-short thumb and a nonuseful index finger stump that was in the way. A neurovascular transfer of the residual index finger phalanx to lengthen the residual thumb and a ray amputation of the second metacarpal restored sensate thumb function for pinch and grasp and eliminated the in-the-way index digit. That case made me realize I had made the right choice in becoming a plastic surgeon.

John Markley provided his recollections of the hand program at the UM from 1974 to 1984:

I was interviewed by Dean Louis in May 1974 as part of the process of my appointment to start in July 1974, at which time I suggested forming a combined Plastic Surgery-Orthopedic Surgery hand service. He was not at all interested, and we agreed to co-exist amicably and compete. At that time orthopedics did not have any microsurgical capability.

When I started in 1974, I was named director of the Plastic Surgery Hand Service, and started a one-afternoon-a-week hand clinic, staffed by me, with one resident (sometimes two, a junior and a senior), and Loraine Smith, one of our nursing aides [Photo 53]. This started out slowly but it gradually built, and had a big boost with the first digital replant I did in 1976 (first in Michigan). Numerous replant cases followed. In addition, I did the first two microsurgical free toe-to-hand transfers in 1978 and 1979 with the residents at that time. However, beyond the microsurgery, the overall hand experience grew nicely. I lobbied and educated other specialties, for example, pediatrics, neurology, rheumatology, emergency medicine, and so on, and cases came in from all those and continued until I left in July 1983. Between then and 1984, I continued to see problem hand cases once a month in the UM Hand Clinic on a consultant basis for cases selected by Dr. Tom Stevenson.

Photo 53: Loraine Smith, LPN, a devoted and highly skilled assistant and clinic nurse.

I started the annual hand/forearm gross anatomy dissection series, three 1.5 hour dissections each fall in 1980 and continued that every year [until I retired in 2007].[26]

This is another excellent example of the great teaching value created by the availability of fresh cadaver anatomy specimens. (There is now a videotape of one of his dissections in the residents’ online teaching library.)

Markley continued,

Markley continued, discussing hand joint replacement with silicone implants:

One contribution John did not mention was the excellent PRS article he published in 1977 describing digital neurovascular island flaps and the discussion of two-point discrimination achieved.[28] In addition, I am a personal recipient of John Markley’s skill by virtue of an indicis proprius tendon transfer to repair a spontaneous ruptured extensor pollicis longus on my dominant hand in 1975 that to this day is functioning perfectly.

Treatment of Skin Cancers

In 1969, in a report in the UM medical journal from members of the Section of Plastic Surgery, the authors presented a statistical evaluation of treatment of basal cell and squamous cell carcinoma in 653 UM patients treated through 1961, thus allowing a five-year follow-up period.[29] Of great significance was the opportunity to use the university’s IBM 7090 computer, which allowed the analysis of the effect of a large number of factors on the cure rates and specifically the variables and treatments that were related to recurrences. Following are two of the most significant conclusions: significance of the specific type of treatment-affected cure rates was at the .05 confidence level and electrodessication and curettage was the most effective treatment and radiation therapy the least in producing cure rates. Location of tumors most likely to recur included lateral nose, internal nares, and external auditory canal. Ulceration-invasive growth pattern and multicentric appearance were also prominent factors for recurrence. The final comments of the authors included, “It is likely that methods of treating skin cancers have improved since 1961, when our present study ended.” It was thought that more effective treatment had been brought about by the following factors: (1) the use of Mohs’s chemosurgical method (Dr. Mohs reported a 0.9 percent recurrence rate in four thousand cases using his technique in a personal communication to the lead author), (2) all radiation therapy was now being given in a new unit by highly improved techniques, (3) most surgical treatments for skin cancers were now handled in the Section of Plastic Surgery. There were three important aspects of this study: an advanced computer was used for analysis; authorship included a medical student (Jesselson) and a plastic surgery resident (Dr. Seaton), an important factor in their education; and results of the study positively affected the subsequent management of these types of lesions. It was clear that complete excision of the lesion at the time of primary operation was essential to lowering the recurrence rate. To achieve this would require close collaboration with a clinical pathologist at the time of primary excision. In addition, the use of the Mohs technique should be strongly considered for specific difficult lesions.

We all saw patients with parts of their faces eaten away as a result of inadequately treated basal cell cancers. Thus, we were always looking for the most effective way of treating these lesions primarily. Our first line of action was a close collaboration at the time of initial excision with our pathologists at SJMH. We would do the initial excision with an adequate visual margin. Before completely removing the lesion, we would mark the specimen with a suture at one edge for orientation. Then we would take the specimen over to the pathology department and, together with the pathologist, decide the technique that would best determine whether the margins were clear. If not clear on initial exam, we would go back and re-excise the exact spot in question. Eventually, we would be told that the excision was complete and that we would either directly close the defect or use an appropriate reconstructive technique. This routine resulted in greatly minimizing recurrences, and we also learned a lot about skin pathology in the process. We were fortunate to have such cooperative colleagues.

However, there were types of basal cell lesions, such as morpheaform type, which were extremely bothersome because of their indistinct borders and their propensity to spread with subdermal extension. We were especially concerned about those lesions near the base of the nasal ala or medial canthus that might be tracking along a deeper plane. This is where Mohs’s surgery became very useful. Dr. Mohs, a surgeon at the University of Wisconsin, proposed and practiced a method of tissue fixation (with zinc chloride paste). He then removed the fixed specimen, mapping the entire specimen and sectioning in such a way as to determine the adequacy of excision. Dr. William Taylor, a professor of dermatology at UM and a close friend of Dr. Dingman’s, became quite a proponent of this technique. A training program was begun in dermatology, and soon, there were more Mohs surgeons available. In the early days, the procedure often took more than one day, which was a disadvantage for the patients. Eventually, the fresh technique evolved that allowed multiple sections to be examined in a single day. When the completed Mohs procedure provided assurance that the excision was complete, the surgeon could proceed with reconstruction without fear of camouflaging a recurrence and minimizing morbidity time for the patient.

Treatment of Cutaneous Vascular Lesions

In 1977, Dr. Grabb, with Dr. Malcolm (Biff) MacCollum (1973–75) and Nick Tan, published in PRS the UM’s experience with the use dermal tattooing in camouflaging cutaneous hemangiomas (port-wine stains).[30] An attempt was made to reaffirm successful results in a previous study from Toronto. Nineteen children up to sixteen years of age who had tattooing of the congenital port-wine hemangiomas were included in the report. A careful attempt was made to match the tattoo pigment with individual skin tones of each patient. This effort was supervised by Nick Tan, from medical illustration, who had training in preparing and mixing these pigments. None of the patients had ultimate improvement beyond 50 percent after at least two and sometimes five treatments. The consensus of the authors was that this technique was not effective enough in this age group of patients, due in part to gradual leaching out of the pigment.

In 1984, Marks, Argenta, and ROD presented five cases of traumatic arteriovenous malformations of the external carotid system.[31] In the cases presented, the lesions were characterized as containing multiple endothelial-lined channels between the arterial and venous system. The etiology was discussed. Accurate diagnosis is important and often can be made by feeling a thrill on palpation or a bruit on auscultation, and by Doppler study. Unless the lesion is small and well localized, its extent and the specific feeder vessels are best evaluated by arteriography. Four of the five cases presented confirmed by history that inadequate excision leads to recurrence and perhaps significant cosmetic deformity. Complete excision and ligation of all feeder arterial vessels is essential, and long-term follow-up in these five cases revealed no recurrence. Significant defects can result from excision that may require reconstruction. A thorough description of the cases was provided along with an excellent review of the literature. In that same year, Krystyna Pasyk, MD; Dingman; Argenta; and Gary Sandall (pediatric ophthalmologist) reported on eyelid and orbital capillary hemangiomas.[32] Congenital capillary (strawberry) hemangiomas are usually present at birth or shortly thereafter. They go through a growth phase and ultimately spontaneously regress or disappear starting by age five or six. However, those that involve the orbital area and obstruct the vision can result in a variety of ocular problems including loss of vision (amblyopia). The article stressed the critical importance of close coordinated follow-up by a pediatrician, ophthalmologist, and plastic surgeon. Treatment must be started aggressively if the lesion enlarges enough to even partially obstruct the infant’s vision. If the visual field becomes totally obstructed, intervention must be carried out within one week to prevent amblyopia. Initially, injectable steroids can be tried, but if not effective in quickly shrinking the tumor, surgical excision must be done. Because these lesions do spontaneously regress, total extirpation is not indicated. Clearing the field of vision is the primary objective.

Skin Flaps

Beginning in 1966, there was a concerted effort both in the laboratory and clinically to study how to improve the efficiency and utility of skin flaps to close wounds. The struggle to successfully close difficult wounds was an ongoing problem for all of us. We were motivated by clinical necessity to find ways to enhance the blood supply to random skin flaps and to find new ways to approach this problem. Time was spent in studying the delay phenomena and exploring various ideas to enhance the vascularity of both random and axial patterned flaps. Examples are the research projects that fellow resident Bob Knode, Bill Grabb, and I contributed to in the VA laboratory in 1966–67.[33],[34] Although we were optimistic at the onset, the results unfortunately showed that IV dextran did not enhance the vascularity of either variety of flap in the pig.

Many of the types of flaps available clinically to us at the time were cumbersome and not always successful. I think back to the necessity of applying cross-leg flaps to avulsion injuries of the opposite lower leg and the morbidity from the necessary immobilization. This was described very well in a paper by Grabb, Don Greer, and Bob Wilensky[35] along with Don Greer’s chapter in Grabb and Myers’ book on flaps.[36]

Dr. Grabb’s interests in skin flaps were wide-ranging and sustained. He became familiar with all the centers and surgeons who were working in this extensive and fascinating field of endeavor. The effort culminated in the publication of the book Skin Flaps[37] in 1975 that Dr. Grabb edited with Dr. Bert Myers, professor of surgery at Louisiana State University (LSU) and a tireless collaborator in flap research. Dr. Frank McDowell, the editor-in-chief of PRS, wrote the foreword for the book. A quote from the foreword clearly stated the book’s importance: “For too long we have not had a book devoted to all aspects of all kinds of flaps. To obtain such information one had to read parts of many books and many papers. Now it is all available to us in a compact volume, both experimental and clinical, written by the leading workers in each phase in the United States and abroad. Herein will be the answer to most of our questions about flaps. And from this we will get ideas for new uses of flaps and a better ways of moving flaps. How fortunate we are.”[38] Quotes from the preface, written by Drs. Grabb and Myers, clearly delineated the up-to-date status of the research and clinical development in the field of skin flaps as of the time of publication: “The principles that have been used in planning a skin flap were developed empirically over a period of centuries. In the past decade great advances as a result have permitted us to proceed with more confidence of success in the clinical use of skin flaps. These advances have been the stimulus for this book.”[39] There were two major divisions in the text. The first ten chapters pertained to some of the recent research on skin flaps. These chapters included flap circulation as well as effects of anesthetic agents and hyperbaric oxygen. The mechanism of the delay phenomenon, including the role of arteriovenous connections, was also discussed. A summary of the anatomy of cutaneous circulation was also presented. Pioneering authors included, among others, John Reinisch, Rollin Daniel, and Bert Myers, and references to Stuart Milton, a flap research pioneer, who had recently died and to whom the book was dedicated, were also present in the book. He was a close friend of Bill Grabb’s and a welcome visitor in Ann Arbor. He was initially responsible for questioning the validity of the absoluteness of length-width ratio in skin flap design.[40]

Continuing from the preface,

Part II was an inclusive group of chapters providing a clear description of all the known flaps available for defects, literally from head to toe, written by experts recruited by the editors from around the world who had actually used these flaps. It was clearly a masterful accomplishment for its time, and it was the model for the book Encyclopedia of Flaps, which Dr. Grabb was working on at the time of his death in 1982. It was published posthumously in 1990[42] and is now in three volumes.

More from the Grabb and Myers preface: “The early determination of blood supply to random pattern and axial pattern flaps deserve emphasis and it was explained that in the clinical situation, one can accurately determine the adequacy of blood supply to both random and axial pattern flaps by the intravenous injection of fluorescein followed by a visualization of the fluorescence under an ultra violet lamp. In an axial pattern flap, a hand-held Doppler flowmeter can help locate and then monitor blood flow in the artery supplying the flap.”[43] Some of this experimental work was carried out at UM in clinical studies by Dr. Grabb with Dr. Sigurdur (Siggy) E. Thorvaldsson (1971–73), published in 1974.[44] It was a report of nineteen patients and showed that the use of IV fluorescein at the time of operation was a reliable and safe method for predicting how much of a skin flap would survive after raising it from its normal anatomic location. The results of this study and others as discussed by Dr. Bert Myers, in chapter one in the book Skin Flaps, gave us confidence in the reliability of the technique. Based on this study, we began to intraoperatively excise portions of skin flaps that failed to fluoresce. We followed this procedure both with reconstructive flaps and surgical ones such as in prophylactic mastectomies. This technique was a precursor to the currently used “SPY” intraoperative flap monitor.[45] Grabb and Myers’ book, Skin Flaps, was the bridge between the era of the pioneering understanding of random and axial flaps and the widespread use of musculocutaneous and fasciocutaneous flaps in the coming years.

Myocutaneous (Musculocutaneous) Flaps

The next dramatic steps with understanding flaps were recounted by Leonard Furlow, who with John McCraw coauthored the last chapter describing the dorsalis pedis arterial flap in Grabb and Myers’ book. In a 2014 editorial posted in the Annals of Plastic Surgery, titled “When Our Vocabulary Changed,”[46] Dr. Furlow explained that before the mid-1970s, the language we plastic surgeons used when we talked about flaps was geometric—length-width ratio, advancement, transposition—or anatomic—cross-leg, abdominal, or temporal, delayed or staged. Flaps, moved in a random network of vessels, often required delay or staging to improve the blood supply or to induce the flap to survive on a reduced blood supply. The few axial flaps previously identified, such as the forehead flap, deltopectoral flap, and neurovascular island flaps in the hand, had very circumscribed uses. The very innovative Dr. Miguel Orticochea reported constructing a penis using a muscle carried on its axial vessels with the overlying skin supplied by perforating vessels from the muscle. Stimulated by that specific solution, John McCraw saw the tremendous potential in understanding and describing a general myocutaneous pattern for the solution of a wide range of reconstructive challenges. When at Emory University, under Dr. Jurkiewicz, Dr. McCraw began defining by dissection a variety of these flaps and, with that knowledge, produced a virtual revolution that changed the field of reconstructive surgery forever.[47] Ultimately, this led Drs. McCraw and P. G. Arnold to begin an annual flap dissection course in 1977 in Norfolk, Virginia, and ultimately to publish McGraw and Arnold’s Atlas of Muscle and Myocutaneous Flaps in 1980.[48]

As is true with a great many revolutionary advances, there is often a simultaneity leading to wider dissemination of the basic concepts. This was certainly true in the case of the advent of myocutaneous flap concepts in promoting the better understanding of the importance of these flaps for a host of reconstructive problems. Two important articles were published in the same year in PRS; the first was by Mathes, Vasconez, and Jurkiewicz, titled “Extensions and Further Application of Muscle Flap Transposition,” in 1977.[49] A little later, in the same volume, McCraw, Dibble, and Carraway published “Clinical Definition of Independent Myocutaneous Vascular Territories.”[50] Mathes andNahai published their book, The Clinical Atlas of Muscle and Musculocutaneous Flaps in 1979.[51]

Within the UM program, there was a sense of being alert to new ideas from national meetings, specialized conferences, personal conversations and bringing them back to Ann Arbor. The importance of this concept was actively supported by both Dr. Dingman and Dr. Grabb. One practical result of this policy was illustrated by the fact that Larry Berkowitz, a junior resident in 1977, went to the first myocutaneous flap dissection course in Norfolk, Virginia, put on by Dr. McCraw. Larry came back and discussed these new concepts with Paul Izenberg, then his senior resident. They discussed these exciting ideas with Dr. Grabb who enthusiastically encouraged them to clearly define the detailed vascular anatomy of all these flaps. Dr. Paul Izenberg recalled, “Little did we know how much this would change the face of all reconstructive surgery. So off we trundled one evening to the cadaver lab and obtained two to three full fresh cadavers. We outlined and prosected ten to fifteen flaps Larry had seen at the meeting including vessels, landmarks, and surrounding anatomy. The entire plastic surgery section showed up a day later for a teaching section. The fun part was that over the remainder of our residency, the residents became the experts on these flaps, helping each other and changing the face of pressure sore surgery and defect closure.”[52] These fresh cadaver dissections were an important advance in the study of surgical anatomy. As mentioned before, no longer were we restricted to the use of embalmed (preserved) cadaver specimens. The availability of these unembalmed anatomic specimens allowed much more precise and detailed dissections especially of small muscles, nerves, and blood vessels. Paul and Larry ultimately defined the anatomy of all the flaps that subsequently entered common usage for a wide variety of reconstructive procedures, including trauma, decubitus ulcers, and reconstruction after cancer resections. These musculocutaneous flaps studied at the time included the gracilis, the tensor fascia lata (TFL), latissimus dorsi, the pectoralis major, the gluteus maximus, the vastus lateralis, and the gastrocnemius. This endeavor led to a much better understanding of differences in patterns in vascular anatomy, which ultimately led to a use of free flaps using direct microvascular transfer. Paul emphasized, “The Section of Plastic Surgery had a great relationship with the Anatomy Department and more importantly, there was no issue getting fresh cadavers for prosection for teaching or individual preparation for surgery. The deaner Bob always had things ready.”[53] We were indebted to the UM gross anatomy department for their willing cooperation in providing the anatomic specimens for our plastic surgery education program through their highly respected anatomic donation program.

Treatment of Decubitus Ulcers

Dr. Paul Izenberg recalled that the availability and reliability of the myocutaneous flap changed the residents’ attitude toward the surgical treatment of these challenging problems. It turned the treatment of these pressure sores into a fascinating exercise to define the best flap and an enjoyable exercise in anatomical dissections to achieve a successful result. Paul recounted, “The surgery on pressure sores which as random or delayed flaps was always a chore. We used to say with the random flaps the weakest part of the flap, the tip, was the most crucial part of the flap, this failure to get a healed wound was not rare. But then it became ‘fun’ for us making it an anatomical challenge with a much better chance of the flap surviving exactly where we needed it! That was a real change from what had gone before.”[54]

It was emphasized to all of us that the most important aspect of preventing these problems in spinal cord–injured patients was the physical therapy teaching about the physical and social changes needed to avoid the pressure injury in the first place as well as avoiding postoperative recurrences.

In the plastic surgery 1972–73 annual report, it is noted that a research project was set up to be directed by Dr. Jim Norris (resident, 1973–74) to evaluate the results of surgical treatment of patients at UM from 1961 to 1971.[55] The objective was to study the rate and reasons for recurrence after surgery, estimate the cost of treatment, and attempt to ascertain the best nursing and surgical care for these patients. In addition, it was decided as a policy to limit decubitus ulcer patients to four on the plastic surgery service at any one time. Dr. Norris (in a letter to me) said, in effect,

It is interesting to peruse Dr. Dingman’s thoughts on the overall management of these difficult patients in the era 1973–74 in the section’s annual report from that year:

Fortunately, the advent of seat “cushion” technology and pressure relief with flotation and airbeds became available—their near universal usage has dramatically helped reduce the incidence of these lesions while also avoiding postoperative recurrence.

Clinical Microvascular Surgery

John Markley, our “go-to guy” in this area, reports on the development of clinical microsurgery in Ann Arbor:

Dr. Markley continued, “In 1983, I got together with Dr. Dingman, Jerry Turcotte, Chairman of Surgery, Robert Bartlett, General Surgery, and Dr. William Smith, the head of Orthopedics, to organize a formal replant service for the University of Michigan. Tom Stevenson who had just joined Plastic Surgery, being appointed by Dr. Grabb before he died, became the director of this joint activity between Plastic Surgery, Orthopedic Surgery, and General Surgery.”[58]

For the residents, the combination of Dr. Markley’s superb microvascular training, the invaluable experience they gained in Dr. Acland’s training program in Louisville (see p. 73), and the personal practice time that they had the opportunity for in the Sargent laboratory provided them with excellent preparation to respond to emergency demands such as major extremity traumatic amputations. Dr. Ernie Manders (1979–81) recounted,

Dr. Bob Gilman (1980–82) recently brought to our attention another dramatic case, the details of which follow:

As Dr. Izenberg added,

Shotgun Injuries to the Face

This was one horrifying and extremely difficult group of patients. The vast majority represented unsuccessful suicide attempts, in which the initial air release from the barrel of the gun in the mouth kicks forward and the main injury is to the midface and jaws. So the patients not only had acute massive wounds but they were also in need of both prolonged reconstruction and psychiatric care. Prior to the era of myocutaneous flaps and free tissue transfer, the reconstructive options were often carried out over several years. These patients’ names remained imprinted in the residents’ memories, and often, as they gathered at meetings, they would say to each other “. . . do you remember Harvey so and so . . .” and recall how one may have done the initial debridement, another a tube flap transfer, and yet a third a bone graft. Reconstructive tools such as a forehead or deltopectoral flap were often inadequate to compensate for the three-dimensional aspects of these complex and massive wounds. The patients were often left having to wear a mask and carry a towel at all times. It was not until the early 1980s that the new reconstructive advances allowed reasonable reconstruction for these desperate patients. As Dr. Izenberg shared, “Still the results with so much tissue missing was always limiting. Hopefully preventive psychiatric care will reduce these horrendous injuries. Face transplant surgery, as it evolves, may also provide more comprehensive reconstruction possibilities.”[62]

Gender Reassignment Surgery

Sometime in the late 1960s, a conference was organized at the request of a UM staff psychiatrist to discuss treatment of transgender patients who had sought care at the university hospital. It was pointed out to us that understanding of transsexualism had progressed to its being considered a specific disease entity and a well-defined diagnosis in the psychiatric literature. The psychiatrist explained that it was a unique condition and not a variant of homosexuality. We were also told that there was no effective or perhaps even justified medical or psychiatric treatment. The current thinking was that, in selected patients, hormonal management and gender reassignment surgery was the best option. Consequently, a team was set up comprising specialists from relevant disciplines, including psychiatry (Dr. Joseph Pearson), psychology testing (Dr. Richard Hertel, PhD), social work, urology (Dr. Joseph Cerny), gynecology/endocrine (Drs. Bob Jaffee and George Morley), and plastic surgery (Drs. Grabb and myself). All potential patients were evaluated by psychiatry, underwent psychological testing, and had a social work evaluation. Additional requirements included cross-dressing as the sex they wished to be, appropriate hormonal therapy, and having lived as a transsexual for up to two years. If successful in these endeavors, then the patients were reevaluated and were required to be accepted as surgical candidates by the entire team. One technique I employed in my evaluation was to see the patient with a medical student who would be unaware of the patient’s condition. If the patient was convincing in manner and appearance to the student, this was an important factor in my final approval. The vast majority of our patients were males wanting to be females and had insurance coverage through the Detroit auto companies where they worked. In general, following surgery, they were usually quite satisfied with their conversion. At the time, we were lining the neo-vagina with skin grafts and contractures in these reconstructions created need for prolonged follow-up for the gynecologists who were the primary caregivers in the follow-up period. This situation eventually led to termination of the program. The female to male patients were more difficult, at that time, as we were limited for penile reconstruction to using delayed, multistaged abdominal tube flaps with an internal lumen for the urethra. The results were less than ideal and tedious for both the patient and surgeon. Even with the limitations and complications, the majority of these transsexual patients were grateful for the team’s sympathetic understanding of their condition and our willingness to be involved in their care. For a variety of reasons, the program was not ultimately sustainable. It was certainly a unique educational experience for us to have a better understanding of this newly described and, in general, poorly understood condition. Newer techniques and more psychological understanding have helped these programs to flourish again within the UM plastic surgery section under Dr. William Kuzon.

Clinical Skin Expansion

Dr. Eric Austad had the most intimate recollections of the program from its inception at the UM:

In 1984, along with Drs. Rohrich and Izenberg, I published a case demonstrating the usefulness of skin expansion during reconstruction of the upper two-thirds of the external ear.[64] The expansion facilitated draping of the otherwise insufficient superior retro-auricular skin over the autogenous costal cartilage framework of the reconstruction. This is a good example of one of the many types of deformities where expansion was being use for distinct advantage.

Breast Surgery

Cleft Lip and Palate

In any discussion on this subject, we must emphasize Bill Grabb’s interest and devotion to the field of cleft lip and palate. This is well illustrated by his very comprehensive book, Cleft Lip and Palate, published in 1971 with coauthors Sheldon Rosenstein, DDS, professor of orthodontics at Northwestern Dental School, and Kenneth Bzoch, PhD, at the University of Florida.[85] It covered all aspects of the cleft sequence, was very authoritative for its time, and received good reviews. In addition to Dr. Grabb, UM contributors included Dr. Dingman along with Ted Dodenhoff, a resident at the time, with a chapter on surgical correction of mandibular deformities in mature cleft patients. The book also included my contribution of a chapter on oronasal fistulas.

As we mentioned in chapter one, Dr. John Kemper was an early practitioner in the treatment of clefts and beautifully stated the case for the multidisciplinary approach to these patients: “Rehabilitation of the cleft palate patient may be likened to a great drama in which there are a number of actors, each playing an important role under the direction of one individual, the surgeon, who is responsible for its management and production. The most distinguished and important character, the central figure in the play, is the patient, whose successful performance is dependent on the skillful guidance of the director [the surgeon] and the combined efforts of all other members of the cast.” In this presentation, he went on to discuss the other critical aspects of care of the cleft patient, including feeding, reassuring the parents that the child will in all probability develop to be a completely normal child, and emphasizing the importance of their continued cooperation in the rehabilitation of the child over a number of years. He also acknowledged the importance of specialized surgical training and achieving not only technical skill but also good surgical judgment. He also stressed the importance of early repair of any lip defect to help mold the displaced alveolar segments, the careful observation for ear infections, and the postsurgical consultation with speech therapists, as well as early institution of active and passive palatal exercises. He closed by stressing that dental care be carried out at the right time and in the right manner including appropriate consultations with a prosthodontist. Finally, he stated the responsibility of the surgeon for timely correction of the commonly associated secondary facial deformities.[86] All of these important aspects taught to us by Drs. Dingman and Grabb formed the basis for our care of the various aspects of the oral cleft deformity. A significant aspect of our care for these children was the financial support available through the generous and well-administered Michigan Crippled Children’s fund. This provided total financial support for the comprehensive care of cleft lip and palate patients until eighteen years of age.

1. Unilateral Cleft Lip (UCL)

Although there was some pressure by parents and relatives to operate on babies with unilateral clefts as newborns, we felt that it was better to wait until about three months of age. Another rule Dr Grabb insisted upon and we all followed was the 10-10-10 marker: 10 weeks, 10 lb, and 10 gm of hemoglobin. The wait usually assured the baby was healthy but, just as important, that the parents had a chance to bond with the child. We watched the parents go from seeing only the cleft deformity when they looked at their newborn child to seeing, at two to three months of age, a beautiful healthy baby with a limited defect. We came to realize this early bonding of the parents and the cleft baby was essential for the future welfare of the child. Many of our cleft patients were referred from the newborn nursery at SJMH. Our good relationship with the pediatricians facilitated our seeing the patients in the hospital shortly after birth. This allowed us to reassure the family that they could expect that their child would be able to lead a normal life before any discussion of specifics of surgical procedures or speech therapy.

Photo 54: Robert Pool, MD.

After Dr. Millard published his classic description of the rotation-advancement technique for repair of the UCL in 1964,[87] this became the standard approach that we used at the UM. It worked well for many clefts. However, we began noticing less-than-satisfactory results in creating lip symmetry in the more severe complete unilateral clefts with excessive vertical shortness in the lateral segment. At a UM-sponsored Cleft Lip and Palate conference in the early 1970s, Dr. Ernie Kaplan from Stanford[88] was the first person to propose a modification of the Millard technique for UCL rotation incision when a back cut was required. He proposed making a slightly curved incision directly over to the lower extent of the proposed back cut, thereby avoiding the curved incision extending up to the columellar-labial junction. This concept, together with Dr. Robert Pool’s modification of the rotation-advancement technique, made it applicable to all degrees of the UCL deformity. Dr. Pool, from Beaumont Hospital in Michigan, described this approach to us in Ann Arbor in a series of lectures as visiting professor (Photo 54).[89] The two main aspects of this modification were to have the rotation incision on the cleft side be placed slightly below the critically important aesthetic unit of the labial-columellar junction. This distance would increase proportionally to the degree of shortness of the lip on the cleft side and be limited to a maximum of 4 mm. The other important technical aspect was that the upper level of the lateral segment advancement flap was placed below the alar base to the same extent as the medial segment rotation incision was inferior to the columellar-labial junction. This idea was stimulated by his recognition of the difficulty of rotation advancement in cases where the dimensions of the lateral lip segment are deficient.[90] This design allowed the lateral segment, when advanced, to unfold and its vertical height to lengthen. The technique proved to be very adaptable to all variations of severity of the UCL. Dr. Markley, using his well-developed sense of spatial relations and mathematical skills, helped the rest of us to understand the subtleties of this procedure. After I had experience using it, I became convinced of its amazing versatility in the repair of all varieties of primary unilateral clefts as well as for secondary revisions and was encouraged to continue to use it and also to teach it. I feel very indebted to Dr. Pool for his willingness to share and teach his technique.

3. Cleft Palate

One of the major early advances in the management of cleft palate patients was recognition of the potential for damage to the middle ear caused by dysfunction of the Eustachian tubes in infants and young children. In collaboration with our ENT colleagues, we instituted prophylactic treatment in all cleft palate patients either when the associated cleft lip was repaired or when an isolated cleft palate was repaired at about one year of age. Myringotomy was performed, fluid removed, and a small silastic tube inserted to allow equalization of pressure in the middle ear through the eardrum, thereby bypassing the dysfunctional Eustachian tube. Avoiding hearing loss was especially important in cleft patients learning speech. With growth and palatal closure, eventually the tube could be discontinued in the older child once normal Eustachian function developed.

Photo 55: The Dingman mouth gag, showing the exposure of the operative field as a result of its proper placement in a young cleft palate patient.

As far as the actual palate repair was concerned, we were forever trying to find the correct balance to achieve acceptable speech and avoid maxillary growth disturbance, and through these years, it was an ongoing process. The operative visualization and the surgical access to these frequently demanding repairs were greatly facilitated by the availability of the famous and widely used Dingman mouth gag (Photo 55).[95] The mouth gag was formulated and manufactured by Richard Sarns of the Sarns Inc. engineering firm in Ann Arbor, Michigan. Mr. Sarns told me that Dr. Dingman had invited him into the OR to visualize the need for improved instrumentation to increase safe cleft palate operative exposure as well as to minimize the necessity for unnecessary assistants around a very small operative field.[96] Sarns designed a multipurpose instrument on a square frame that met four essential requirements: adjustable tongue depressors to stabilize the endotracheal tube as well as the patient’s tongue; provide a secure, as well as anatomically safe, open mouth position; lateral cheek retraction; and tightly coiled small springs attached to the upper and lower horizontal bar to hold multiple suture lengths after they had been tied in place to allow them all to be trimmed in a single maneuver. Three different sizes of tongue depressors were made available to allow the instrument to be used in all ages of cleft patients. This well-designed instrument quickly became an essential mainstay for all types of cleft palate surgery and is now in worldwide use.

The idea of closing the soft palate first, allowing the hard palate cleft to narrow, and delaying hard palate closure until eruption of the primary first molar at around thirteen to nineteen months was very appealing for minimizing potential for palatal narrowing except for the disadvantage of an extra operation. Once we learned that avoiding undermining posterior to the maxillary tuberosity would minimize growth disturbance, we began to rely on the straight line von Langenbeck closure of the entire palate, often reinforced by a vomer flap in wider clefts. Palatal lengthening procedures using setback techniques were also performed but had the disadvantage of leaving too much raw surface in the anterior palate. Dr. James Hayward, DDS, head of oral surgery at UM, taught us that extending closure of the soft palatal layers posterior to the uvula (low-draped palate) did in fact functionally lengthen the palate, and we began to use this technique routinely. Finally, recognition of the abnormal anterior orientation of the levator muscle in the cleft encouraged us to reorient the muscle in a horizontal end-on position in the closure of the soft palate. When Furlow’s double Z-plasty procedure for closure of the soft palate[97] was reported, we began to use it. We felt it was the operation of choice for submucous clefts but could be problematic on quite wide complete clefts.

In response to the early uncertainty about which cleft closure would produce the best overall long-term result, Dr. Grabb proposed a prospective, randomized long term study.

The project was described in the 1972–73 annual report. A cooperative study of cleft palate surgery would begin in 1970 and was planned to run for at least seven years. Its purpose was to objectively determine which of four different cleft palate repair procedures, selected randomly, would give the best results with regard to speech, facial growth, and hearing.[98] The planning included dentistry, speech, and ENT, in addition to plastic surgery. It was hoped that there would be conclusions within ten years. To acquire the ninety patients[99] needed for the study to have the best chance of statistical significance, Dr. Grabb invited seven other plastic surgery programs from the United States and Canada to participate in the study. To my knowledge, this was one of the nation’s first multiinstitutional prospective outcome studies. Unfortunately, when Dr. Grabb died, a lot of the momentum for the study dissipated and the study eventually ebbed before enough patients could have the necessary and required long-term evaluation.

Rhinoplasty

Dr. Dingman’s openness to new and better ideas led the rest of us to be aware of new advances in rhinoplasty. His friendship with Dr. Joseph Tamerin from New York City led Dr. Tamerin to be visiting professor at UM in 1969. Dr. Tamerin operated on one of our patients with a resident assisting. He used the intracartilaginous (cartilage splitting) incision for approaching the tip in rhinoplasty. This demonstration and the resulting natural-looking tips in the patients that he presented later that day in conference encouraged all of us to start using that approach, moving away from previous experience with either the intercartilaginous retrograde approach or the delivery technique. Then, in 1971, Dr. Dingman sent Carl Berner, resident 1970–72, to an ENT facial plastic surgery rhinoplasty conference, and Carl brought back all sorts of new concepts, including the open approach, that we discussed and began to use with difficult tips, particularly in teaching situations. Carl reported to me recently, “I remember how thrilled I was to be sent by ROD to ‘spy’ on the facial plastic surgeons regarding their techniques. I had no idea how I would be received, as at that time there was some animosity between the specialties. I need not have been concerned. Dr. Dingman’s reputation preceded me. I was welcomed by all. I believe what I learned was valuable to me in my practice and to all of us. Rhinoplasty was a big part of my practice. What I learned through the rhinoplasty meeting gave me more confidence.”[107] The friendliness and respect shared by Dr. Dingman and those ENT facial plastic surgeons was in part due to the respect Dr. Dingman had gained by his participating in their teaching conferences and having accepted ENT trainees into our residency program. He once said to me, “There should be no limits on education. You should be willing to teach to whomever wants to learn.”[108]

Another “light bulb” experience occurred at an ASPRS meeting in Houston in 1974. Dr. Jack Sheen presented his revolutionary work on the correction of secondary rhinoplasty. We had all been struggling with these deformities. To correct them, we had been removing scar tissue and further reducing dorsal structures to correct the common “pollybeak” deformity. Dr. Sheen turned the tables on us as he showed markedly improved results using augmentation of tip, dorsum, and radix rather than making any further reduction. The underlying concept he presented was to increase the structural support and expand the skin envelope, thereby improving shape and function. I can remember a collective “gasp” in an audience of about one thousand five hundred plastic surgeons as Dr. Sheen presented what I interpreted as amazingly good results. A better understanding of the underlying concepts of that presentation, published in PRS 1975,[109] helped us to define the factors in evaluating a primary rhinoplasty patient that, if uncorrected or made worse, could lead to the necessity for a secondary rhinoplasty. These new concepts helped us to improve the treatment of secondary patients as well as better evaluate our primary rhinoplasty candidates.

Sometime during the early 1980s, I was exposed to the idea of suture techniques to control the shape and position of the tip cartilages. This happened at a university hospital teaching conference in ENT to which I was invited to hear the visiting professor, Dr. Gene Tardy, a well-known facial plastic surgeon. I realized that it was a real advance in rhinoplasty surgery to have available a technique that was very effective, nondestructive, and reversible. Based on this experience, we modified our techniques and significantly improved our results.

Dr. Dingman always placed a high premium on accurate and easily understood terminology to eliminate confusion in discussion of operative details. An example of this attention to detail appeared in the article he and Paul Natvig published in PRS in 1982, near the end of both of their careers, clarifying the incisions for rhinoplasty.[110] This article was an effort to clarify by description and illustrations the details and proper names of the incisions used to gain access to the alar cartilages during rhinoplasty. The important distinction between the oft-confused infracartilaginous incision at the caudal edge of the alar cartilage and cephalic to the soft triangle, and more caudal marginal (or rim) incision was graphically illustrated.

In addition to all this stimulating information, the advent of residents coming through the program with prior ENT training gave all the other residents, and particularly those of us on the faculty who were interested in rhinoplasty, an ongoing tutorial on surgery of the nose, especially with regard to the septum and nasal physiology. This group of residents had been schooled in the technique of open rhinoplasty, which had advantages for correcting complicated aesthetic tip deformities, for secondary cases, and especially for cleft lip nasal deformities. As we began to use the open technique, the obvious advantages for OR teaching became evident. One of the most practical suggestions concerning technique came from Erlan Duus (1983–85). He introduced me to a dental instrument, the amalgam tamper, for ease in defining the proper dissection plane in septal surgery. Those old enough to have had dental fillings might remember seeing one. The exact instrument he recommended has small sharp serrations on the square end. I quickly realized that it was very efficient for “scratching” through the perichondrium of the nasal septum down to the proper layer for dissection without cutting into the cartilage. It seemed to me far superior to either scissors or a knife. I found that, after starting the dissection, if I got out of the proper layer, a few “scratches” would put me back into the proper dissection plane.

Dr. Jack Gunter had been acting head of ENT at University of Texas Southwestern (UTSW), prior to starting his plastic surgery residency with us in 1978. Shortly thereafter, he and I recognized our mutual interest in rhinoplasty. He took the time to discuss with me most of my preoperative rhinoplasty cases. He taught me many of the fine points of clinical analysis and operative technique of rhinoplasty that he had learned both from his ENT training and from his fellowship with Dr. Jack Anderson, a well-respected facial plastic surgeon. After he completed the residency at Michigan in 1980 and went back to Dallas, Jack and I talked several times and came up with the idea of a postgraduate course including cadaver dissections, didactic instruction, and patient presentations. We both felt it was necessary to augment plastic surgery rhinoplasty training for residents, and there was also a need for teaching these basic ideas to recent postgraduates. The first course was at UTSW in Dallas in 1982, where Jack was a faculty member. He recruited other faculty from Dallas and Houston, including Sam Stal, Steve Byrd, and John Tebbets. We talked about having a meeting the next year in Ann Arbor and then alternating sites every other year, but Bill Grabb’s sudden death put that plan on hold. By the time everything settled down at UM, Dr. Rod Rohrich, another one of our alumni (finished in 1985), had graduated and gone to UTSW to join the faculty. Together with Rod and Jack Gunter, the annual Dallas Rhinoplasty Course became well established there and has continued as one of the premier rhinoplasty international conferences for over thirty years. The formal and informal discussions among the faculty, which included some from ENT, were the stimulus that eventually led to the formation of the Rhinoplasty Society. The nasal anatomy video that Paul Izenberg, Bob Gilman (1980–82), and I created for basic teaching in the Dallas course continues to be useful and a valuable part of the curriculum for teaching our residents rhinoplasty at Michigan.

Congenital Protruding Ear Deformity

Several events early on contributed to the evolution of our otoplasty technique for protruding ear deformity. Dr. Stenstrom, in 1963, published his technique for shaping the curve of the antihelix with linear abrasions.[111] Dr. Dingman was impressed that this was an excellent idea, and he then developed a new instrument by taking the two halves of a Brown Adson forceps, bending the stems in two different directions and putting a handle on each one so the instrument in the surgeon’s hand would easily follow the curve of the antihelix of both the right and left ears. This was the origin of the Dingman ear cartilage abrader, another of ROD’s many practical and ingenious modifications. At about the same time, Mr. John Mustarde of Scotland, later to honor UM as visiting professor, described the use of mattress sutures to create a gently curved antihelix.[112] In younger children with more pliable cartilage, probably with either the abrasion or the mattress sutures, the correction would hold up over the long term. However, we felt that it was safer to create the curve by abrasion and then use the mattress sutures for more secure reinforcement. This combination of techniques seemed to be particularly useful in older children or adult patients where more mature, stiffer cartilage might cause the deformity to reoccur after either simple abrasion or just the mattress sutures. Later, in 1979, Dr. Isaac Peled, one of our fellows from Israel, and Dr. Dingman described a modified technique.[113] The final important key to success in our otoplasty evolution was provided by Dr. David Furnas in 1978 whose published article demonstrated that reducing the overprojecting posterior concha wall did not require cartilage excision but it could be repositioned posteriorly with the use of concha-mastoid sutures.[114] The repositioning of the concha was aided by slightly thinning the floor of the concha and removing adjacent soft tissue just posterior to it, thus leaving a space in which the concha could be set back. Another technical aspect was realizing that the standard elliptical postauricular excision when closed could overcorrect the frontal profile of the middle of the external ear. We found that a dumbbell-shaped incision was more desirable and much less likely to cause overcorrection. Otoplasty for protruding ears was one of the most satisfying operations for the patient and surgeon. It was a delight to observe the excited positive response when patients, both young and old, viewed themselves in a mirror at the time of dressing removal.

Face-Lift Experience

The procedure of face-lifting early on was basically a subcutaneous dissection and tightening of the skin, frequently associated with bilateral upper and lower lid blepharoplasty. All this began to change after the publication of Dr. Tord Skoog’s book in 1974 about the deep fascial dissection in the face.[115] Then, in 1976, Drs. Mitz and Peyronie published a detailed description of the SMAS (subcutaneous musculo-aponeurotic system) fascial layer in the face.[116] Because of the improvement in the nasolabial fold and less tension on the dissected skin cheek flaps, there was subsequently a lot of enthusiasm for using these newer deeper dissections. Moreover, coming into common usage were procedures on the platysma muscle, in which the lateral portion of the muscle is divided and then suspended, thereby tightening the still-undissected overlying skin. We also realized that a submental Z-plasty of the central platysmal bands could improve the anterior neck contour. This was associated with procedures of imbricating the subdermal soft tissues under the chin to correct the “witch’s chin” look. We also used selective chin augmentation to improve the acuteness of the cervical-mental angle. In 1985, after the introduction of cannulas for liposuction, we began to use small, flat, blunt cannulas as subcutaneous dissectors for the cheek and neck. This idea was introduced to me by one of our residents, Abram Nguyen (resident, 1985–87). This technique proved to be less traumatic than sharp dissection. We found that with gentle pressure, we could create subcutaneous tunnels in the proper plane that could later be connected by selective sharp dissection under direct vision.

The deep plane dissection techniques continued to evolve but those of us favoring a more conservative approach began to rely on plication of the SMAS layer and then began to use the lateral SMASectomy described at a meeting by Daniel Baker of New York City.[117] We were influenced by the article by Baker and Conley in 1979 about danger of facial nerve injuries during face-lifts.[118] It certainly encouraged us to take a more critical look at the deep plane approaches because of the possible injuries to branches of the facial nerve. Conley and Baker very clearly outlined the anatomy of the various branches of the nerve and how they might be damaged by some of the techniques in use at the time. The article described in detail the course of the ramus mandibularis of seventh nerve and showed it to be much more variable in its relation to the lower border of the mandible than the description in the study of preserved cadavers by Dingman and Grabb in 1961. This supported our conviction that it was essential to use fresh cadaver material for all our anatomic dissections for them to be reliably translated into clinical situations. We followed that in subsequent anatomic dissection projects. We also paid close attention to Peter McKenny’s description in 1980 of how to avoid injury to the greater auricular nerve in the posterior neck.[119]

In 1977, Dr. Ron Wexler published an article concerning possible incisions for male face-lifts based on the experience he gained while at Jackson Prison as a resident.[120] He emphasized the importance of and illustrated techniques to ensure leaving adequate hairless preauricular skin posterior to the sideburn at the end of the procedure.

Paul Dempsey (resident, 1976–78), who finished his training along with Eric Austad and Paul Izenberg, introduced to us in the early 1980s the concept of a subperiosteal approach through a coronal incision to elevate the midface. Dr. Izenberg and I did fresh cadaver dissections to help define the fascial relationships in the lateral forehead and dissection down to the zygomatic arch where a subperiosteal dissection over the zygoma allowed safe dissection and suspension of the deeper layers of the midface.

During those years, we became convinced that it was very important to determine whether the aging patient’s preoperative rationale for improvement was based on her own feelings of decreased self-esteem, or on wishing to have career advancement with a more youthful appearance. We found that these valid patient desires correlated well with the best assurance of a satisfied and happy patient postoperatively. This kind of preoperative assessment required a thorough pre-op interview using a lot of open-ended questions to ensure that the patient’s motivation was not based on something her husband or a friend might be insisting on. The value of this approach was confirmed by a study by Goin, Burgoyne, and Goin in 1980. They reported that a patient’s desire to “improve their self-image and to advance their career were reasonably reliable predictors of [postoperative] psychological improvement.”[121] In addition, we were always concerned about the effect of smoking in face-lift patients and usually required them to stop smoking for at least six weeks preoperatively. Our concern was confirmed by a study reported by Rees in 1984 that smoking did increase the risk for cheek flap vascular impairment postoperatively.[122] We also applied this rationale to operations such as abdominoplasty and even, in some cases, reduction mammoplasty and breast ptosis.

Brow-Lift and Blepharoplasty

Drs. Dingman, Peled, and Izenberg stated at the beginning of their article in 1979, “Forehead wrinkles, drooping eyebrows, and blepharoptosis are some of the earliest signs of the aging face. Loss of skin elasticity in conjunction with gravitational forces upon the forehead, brow, and upper lids results in a constant tired or angry expression. These changes are progressive . . . and do not reflect the patient’s true personality. Attempts to correct this condition by [eyelid] skin excision alone are usually ineffective and disappointing to both patient and surgeon.”[123]

This point of view reflected very accurately the importance that Dr. Dingman always stressed, with both the faculty and residents, of assessing the whole face whenever evaluating a patient’s aging changes. Seeing post-op patients with him in his office, we were witness to the profoundly positive effect that the alleviation of the “tired and angry” look had for the patient, often as, or more, important than improvement in the lower face. The article also discussed the various approaches for these corrections, including transcoronal, either through the scalp or at the hairline in cases of high foreheads in females or also under special circumstances, that is, a male patient, using a forehead wrinkle for access. These approaches were all eventually superseded by the endoscopic approach to forehead and brow-lifts.

We were all influenced by the seminal work presented by Dr. Salvador Castanares describing the anatomy of the herniated intraorbital fat and how to deal with it safely during blepharoplasty surgery. His work became the mainstay of our approach to “baggy eyelids.”[124] During those years, we were also constantly reevaluating our results with blepharoplasty. We gradually became more conservative about fat removal in the upper lids, except for the nasal fat compartment, in an effort to avoid the “hollowed out” look. We also removed less upper eyelid skin in conjunction with brow-lifts, thereby minimizing the risk of a post-op patient being unable to close his or her upper lids comfortably, especially at night. In the lower lids, we always had the patient (under local and light sedation) open his or her mouth widely before excising the lower lid skin. Using skin-muscle flaps and tightening the orbicularis laterally helped. These were the days before common use of canthopexy. We also repaired senile ptosis due to levator dehiscence, but routinely referred the congenital cases to pediatric ophthalmology. When patients presented as adults with an unclear history, a high school photograph was most helpful in ruling out whether the ptosis might be congenital. We were also on the lookout for cases of myasthenia gravis that can sometimes present with ptosis as an initial symptom to avoid surgery and make sure the patient received proper medical evaluation and treatment.

Mr. John Mustarde of Scotland was a good friend of Dr. Dingman’s and a visiting professor more than once, as well as a fishing companion. He graciously introduced all of us to the fundamental principles of reconstruction of resected and traumatized eyelids. His famous book Repair and Reconstruction in the Orbital Region[125] became a bible for us and provided a basis for dealing with many complex problems. We all felt deeply indebted to this very learned and charming Scotsman (Photo 56).

Photo 56: Mr. John Mustarde, visiting professor from Scotland, with Dr. Dingman in the Dingman Library.

Liposuction

Although the use of suction and a sharp curette to remove subcutaneous fat was first published in PRS in 1978,[126] this idea did not receive much attention until, in 1983, Dr. Illouz of France published his results of lipolysis in three thousand cases, having performed it since 1977.[127] There was a lot of skepticism about the technique in the United States, but finally the ASPRS appointed a committee to evaluate the procedure. A group of plastic surgeons went over to France and came back with rather glowing reports after spending time with Dr. Illouz and evaluating his work. There were arguments whether the technique should be wet or dry, but the wet technique of Dr. Illouz seemed to have less bleeding associated with it.

There were some postgraduate teaching conferences on liposuction set up by respected plastic surgeons, and several of our faculty and residents attended these training sessions. Many of us became convinced that the technique, as described by Dr. Illouz, was effective with minimal morbidity in the removal of localized collections of unaesthetic subcutaneous fat accumulation. It seemed to be particularly useful in the lateral hips, abdomen, and in the submental area of the neck. We were also sure that this was not indicated as a substitute method of weight loss in truly obese patients.

The worry about overcorrection was frequently an issue with the then available large diameter cannulas. As small diameter blunt cannulas became available, they allowed much more finesse in removal of fat and avoided getting too superficial where it might result in rippling under the skin, one of the complications of this type of procedure. When the tumescent technique of infiltrating large volumes of saline containing very dilute local anesthesia and very dilute epinephrine was introduced, it became possible to carry out the procedure in an ambulatory setting with supplemental IV sedation. With greater experience, we learned some of the limitations of this procedure early on and tended to avoid the medial thighs, because the skin did not contract well. We had some good results, and ultimately, we were able to combine lateral flank liposuction together with the standard abdominoplasty, but avoiding suction in the abdominal flap. It is interesting to note that currently some type of liposuction is the most common aesthetic operation performed in this country. Of course, liposuction has gone on to much wider use, including collecting fat for autogenous fat transplantation.

Facial Fractures

With the publication of their book, Surgery of Facial Fractures, in 1964,[128] Drs. Dingman and Natvig brought the fundamentals of caring for these injuries to our attention in Ann Arbor, as well as to the plastic surgery community and the world beyond. It bears mention that Dr. Child, whose political skills supported the development and formation of the Section of Plastic Surgery in the years leading up to the publication, wrote the foreword to the book. It is only speculation, but one wonders if the high regard for the authors expressed in the foreword reflected his expectation of Dr. Dingman’s potential as a great teacher. Quoting Dr. Child, “The text by Doctors Dingman and Natvig encompasses past and present knowledge of facial fractures. It clearly points the way toward a better understanding of one of surgery’s most humanitarian accomplishments: the mending of fractured faces . . . the authors . . . have captured the past with charm and the present with vigor. The ability to teach their skills by word and by picture is limited only by their student’s capacity and motivation to learn.”[129]

The book’s publication preceded by two years President Lyndon Johnson’s signing the law making automobile seat belts mandatory in 1968. However, it was not until the mid-1970s, when the development of the enhanced seatbelt reminder (ESBR) became universal and seatbelt usage increased from around 15 percent to 70 percent, that these serious facial injuries saw a marked reduction. So for the first ten years after publication, all types of facial fractures were always a big part of our practice. Dingman and Natvig’s book provided a description of types of injuries for each anatomic location as well as step-by-step illustrations of the necessary corrective maneuvers, and the book became an essential guide for surgical correction. The authors described and illustrated the use of the internal suspension sutures from a stable frontal bone to facilitate intraoral suspension of the maxilla so necessary in the management of those complex cases of skull-facial bone disjunction. The epilogue of the book was written by G. Kasten Tallmadge, a colleague of Dr. Natvig’s at Marquette Medical School and a friend of Dr. Dingman’s. It is a beautiful description of the part of the body so intrinsic to the art of plastic surgery. Quoting in part, “Is there another part of the body which is more nearly one’s self than the face? The incredibly complex arrangements of the parts from the microscopic to the massive have given to man alone . . . the power of intelligible speech and the great gift of his ability to make music. The ceaselessly mobile lines of the countenance conceal or reveal the recondite workings of the spirit.”[130]

Although car safety improvements significantly reduced their incidence, facial fractures resulting from a variety of other etiologies remained a significant part of our trauma care. As an aside, I learned the hard way about the importance of knowledge of pre-op occlusion in conjunction with a case of a patient with LeFort II midface fractures along with mandible fracture. At operation, we applied the direct interosseous wiring and suspension wiring techniques. I got the displaced structures back into what I thought was very nice occlusion. By the next morning, the patient had pushed his lower jaw forward and was in a Class III relationship. I was confused by it but his mother said, “You know I think he may have always looked like that.” Because the patient lived locally, we contacted his dentist and obtained his pre-op dental impressions and realized that he was prognathic before the injury. It was a good lesson to me to always know as much as you can about a patient preoperatively.

Naso-orbital fractures were one specific type of severe facial fractures not discussed in great detail in Drs. Dingman and Natvig’s book. Early on, we recognized the uniqueness of these complex injuries from a frontal force pushing the nasal mass posteriorly into the lacrimal-ethmoid structures. Associated fractures of the frontal sinus often involved the posterior wall and the anterior cranial fossa. To achieve an accurate diagnosis, the clinical exam and regular x-rays had to be followed by open reduction. Direct wire fixation was necessary after reducing all the displaced fragments, along with both neurosurgical and ENT consultation for management of the frontal sinus fractures unless the injury was restricted to the anterior wall of the sinus. By 1969, Drs. Dingman, Grabb, and I had gained enough experience with these cases to report our findings in Archives of Surgery.[131] In 1979, Drs. Dingman and Izenberg contributed a comprehensive review of the possible complications of facial fractures as well as facial soft tissue injuries in John Conley’s textbook on head and neck surgery complications.[132]

Maxillofacial Surgery

This was a special interest of Dr. Dingman’s from the beginning of his career. We were all intrigued by the collaboration that had developed between him and an inventive orthodontist in Ann Arbor, Dr. Robert Ponitz, DDS (Photo 57). Once a decision was made as to whether the maxilla, mandible, or both were to be modified, Dr. Ponitz made models and splints to show exactly what had to be done and what the exact dental occlusion was to be postoperatively. He excelled in doing preoperative orthodontics so that when the surgery was done, the teeth fit nicely together in the most desirable occlusal relationship. This collaboration had led to the evolution of quite sophisticated planning and immobilization techniques. For those of us who were not trained in dentistry and the fundamentals of dental occlusion, it was a bit of an uphill battle to learn these concepts, but by working closely with Dr. Dingman, we were encouraged to branch out on our own with the help of his close friend and colleague, Dr. Ponitz. Many of our maxillofacial patients were adults with secondary cleft lip sequelae who had orthognathic deformities. Before the sagittal split mandibular procedure achieved popularity (it was never favored by either ROD or Dr. Ponitz), we performed vertical ramus osteotomies or body ostectomies for mandibular setback. We would often go to Dr. Ponitz’s office before the case and go over the cephalograms and the models, and look at the splints. He was extremely cooperative and so interested in the actual surgery that he would join us in the OR. As he was a member of the medical staff at SJMH, he could scrub in and assist us, and his on-the-spot analysis was always helpful.

Photo 57: Robert Ponitz, DDS, speaking with Dr. Dingman at a Grabb balloon launching.

An interesting example of this collaboration with Dr. Ponitz to solve a unique clinical problem was published in 1969 in PRS.[133] The article referred to a previous successful case (from another institution) of functional sternocleidomastoid muscle (SCM) transfer to treat masseter muscle atrophy secondary to poliomyelitis. The patient in the current article had congenital absence of bilateral masseter muscles. Seen as a teenager, he was unable to actively close his mouth, having to position his chin on his chest and push his head forward to achieve closure. He also had a massive open-bite deformity and absence of mandibular angles. Two mandibular body osteotomies and iliac bone grafts were required to reshape the mandible. Both SCM muscles were transferred on pedicles containing the accessory nerve and occipital artery. They were positioned between the zygoma and lower border of the mandible. Both transferred muscles regained their function and allowed the patient to actively close his mouth. Dr. Hudak related to me his experience with another application of transferring the SCM:

Dr. Dingman, over the years, attracted many patients who were suffering from malfunction of the TMJs from a variety of causes. Many of them were severely symptomatic. He worked out a safe surgical approach to both the upper and lower aspects of the joint, allowing him to refine his surgical procedures. He reported his surgical results in two articles: the first with 440 cases in 1969 coauthored with a resident at the time, Dr. Eric Constant,[135] and the second in 1975, coauthored with another resident, Dr. Richard Lawrence and Dr. Dingman’s son David, a plastic surgeon on the faculty of the University of Utah, reporting on another twenty-five cases.[136] The surgical approach to the TMJ was thoroughly described and illustrated. A significant proportion of the patients benefited from the variety of surgical procedures.

During these years and subsequently, it was discovered that one of the main underlying etiologic factors leading to dysfunction of the TMJ was unresolved traumatic dental occlusion. Recognition and correction of it as well as prevention of the resulting chronic stress on the TMJ, with a removable dental splint worn at night, ultimately resulted in a significant diminution of the difficult cases. After being contacted by the authors for comment about the TMJ reports, Dave Dingman replied,

Dr. Dingman also did a lot of other types of maxillary surgery, and there were always the possibility of risks. Dr. Lenny Glass (1968–70) recounted such a tragic case during his time as a resident, “I remember so vividly the teenager who exsanguinated in his hospital bed apparently from iatrogenic damage to his carotid artery (a rare complication) which occurred five to six days previously during one of ROD’s first LeFort II advancements. I never forgot that. A curved osteotome was used to blindly separate the perpendicular plate from the maxilla. Seemed too risky a procedure to do without visualization so I never did one.[138] It is probably important to emphasize the dangers and risks faced by pioneers like Dr. Dingman in performing these difficult procedures for the first time. We do not always remember the debt we owe to these innovators as these complex operations can now be performed much more safely on a routine basis.

Another recollection came from Bruce Novark (1972–74) about ROD’s open-mindedness in regard to residents’ assessments of a problem:

Lip Reconstruction

Dr. Dingman demonstrated his characteristic interest in innovation in two instances with ideas suggested by residents. One was with Ron Wexler (1970–72) in reporting a case of a large subtotal excision of the lower lip excluding the commissures in an older patient with a redundant upper lip. The article described two Stein-Eslander Abbe style flaps that were designed to extend up just lateral to the nose and rotated into the lower lip on skeletonized superior labial arterial pedicles. These were divided in a couple of weeks providing adequate functioning lip balance in a difficult situation.[140] The other instance was with Grant Fairbanks (1969–71), who thus described it: