History of Rhinoplasty

History of Rhinoplasty

The word rhinoplasty is derived from 2 Greek words, rhino, meaning nose, and plasikos, meaning to shape or mold. Since the beginning of recorded time, man has considered the nose to be a key feature, if not the key feature, of facial appearance, beauty, and dynamics. However, because of its central facial location and weak cartilaginous support, the nose is relatively susceptible to disfiguring infection, trauma, pathologic entities, and human-associated carnage. If a person were to be so afflicted, these potential deformities could impose serious alterations to work, social life and psyche. In fact, because the nose has been considered the “organ of reputation,” the purposeful amputation of the nose, rhinokopia, was, and is, meant to strip a person of his or her personal honor.1,2 IN THE BEGINNING A papyrus is an ancient form of paper made from the papyrus plant that grows wild in the marshes of the Nile River. The first historical annotation regarding the surgical treatment of nasal deformities is cited in a papyrus named after Edwin Smith. Smith, an American Egyptologist, bought the papyrus from a dealer in Luxor, Egypt, in 1862. The document dates back to approximately 3000 BCE. Dimensions of the papyrus measured 4.68 m long and 33 cm wide, and was divided into 17 pages. The first transliteration of the papyrus was made by James Henry Breasted in 1930. The papyrus was translated a second time in 2006 by James P. Allen, who was the then curator of Egyptian Art at the Metropolitan Museum of Art in New York, using a more modern understanding of surgical verbiage.

At times, the treatment of nasal structural mutilation was surgically attempted by using rudimentary bronze instrumentation. Mutilation was a punishment meted out for major civil offenses, for example, wives leaving the house without permission, adultery, and theft; even lack of female sexual response could lead to punishment causing the recipient visible and lasting humiliation. Captured enemies sometimes were made to suffer the same ill fate as a warning to other would-be adversaries. The treatment of medical problems involved the use of plugs, swabs, linen, and tampons. Strips of adhesive plaster were used for drawing together wound edges. More serious wounds were closed with needles made of materials such as bone, silver, and copper. Surgical sutures were fabricated from plant fibers, hair, or linen. Nasal fractures were treated with stiff rolls of linen. Other informational pieces concerning nasal deformities were addressed in the Nuzi Tablets (1600–1350 BCE), which originated in the ancient area of Nuzi, 10 miles southwest of the city of Kirkuk in modern Iraq.6 The Ebers Papyrus, which is the largest of the medical papyruses and is written in hieratic, devotes an entire section to nasal deformities and their correction. The Ebers Papyrus was also bought by Edwin Smith from an unknown source but was sold early on to Georg Ebers, a German Egyptologist. The papyrus measures 20 m long and has 110 pages. It is dated at 1534 BCE, but parts may have been copied from earlier texts dating back as far as 3400 BCE.5 At approximately the same period of time, and as an extremely dynamic, historically significant corollary, one must note with considerable respect the fifth century BCE Ayurvedic physician, Sushruta, who lived around the same period. Although born of a lowly priestly class, the Koomas (potters), he became a professor of medicine at the University of Benares. Within his series of texts, Sushruta Samhita, written in Sanskrit (a historical branch of Indo-European languages), he outlined several surgical procedures (300) and described several surgical instruments (121). However, because his writings were in Sanskrit, and the Egyptian writings were in hieroglyphics, the spread of shared medical knowledge was greatly mitigated because of expansive geographic communicative areas. In addition, there was a limited amount of commerce between the areas, even though Alexander the Great from Macedonia in Northern Greece invaded India in 327 BCE. However, his troops lasted there for less than 10 years. Since purposeful facial deformation was not exclusive to the area of the Fertile Crescent, in India also, there was much opportunity for interested physicians to attempt to repair several contemporaneous facial mutilations. One of the most famous repairs that is associated with Sushruta is the surgical correction of cutoff noses by the transfer of pedicled forehead or cheek flaps to the nasal deformity.3 Sushruta is also credited with many other surgical procedures, such as those associated with the treatment of cataracts, hernias, lithotomy, and cesarean sections.7–9 Nasal disfigurement was used not only on people who made up the average populace but also on societal members of prominent standing. Emperor Justinian II of the Byzantine Empire (circa 700) was overthrown and had his nose mutilated (rhinokopia) and his tongue slit open (glossotomia). The mutilation was performed in front of thousands of cheering former subjects in the middle of the Hippodrome, the sporting and social center of Constantinople, itself, the capital of the Byzantine Empire. The purpose of the mutilation of his nose and tongue was to permanently discourage him from future attempts to regain his throne as emperor. However, after nasal reconstruction, in the Indian manner, and a healed tongue, he was able to return to power. The effects of the mutilation and repair may be noted in his Carmagnola marble statue likeness.10 In the first century AD, Rome became a medical center. Two outstanding physicians who lived in Rome and discussed tissue transplantation and treatment of facial defects were Celsus and Galen. Interestingly enough, both physicians were Greek.

THE ERA OF DARKNESS

Up to this time, only reconstructive nasal surgery was performed. This concept was carried through the Medieval age and up to the Renaissance periods. Very little, if any, surgery to improve appearance was performed during the Dark Ages (fifth to fifteenth centuries).4 In 1163, Pope Innocent III and the Council of Tours proclaimed that surgery was to be abandoned by the schools of medicine and all decent physicians. The church believed that surgery was interfering with God’s plan.5 In fact, the performance of a surgical procedure (deemed a manual operation) by an educated physician was considered below his dignity. However, surgical procedures were being performed surreptitiously and were being kept alive by passing on the principles from generation to generation and from one civilization to the next.

In this manner, the status quo was maintained but not advanced to any meaningful degree. In 1442, an Italian surgeon from Sicily named Branca de’Branca introduced a method of using forehead and cheek flaps for facial reconstruction. His son Antonius modified the technique by using the arm as the primary donor site and delaying the initial transfer of the graft. The technique became known as the Italian method. But because of the potential for severe church reprisals, the surgeries that were performed were veiled in secrecy with no publications or even collegial comments.5 Pfalzpaint (1450), a German surgeon, described the suture of a biceps flap to the face, which was initially held in position with bandages for several days before the pedicle was separated to form the nasal dorsum.4 Gasparo Tagliacozzi (1546–1599) was an Italian surgeon and anatomy professor from Bologna. During this “dark intellectual era” when emphasis was placed on the mundane, he produced scientific writings about his surgical treatments and was given the most credit for the arm flap to the facial area procedures. His fame was great, and after his death, the city fathers of Bologna erected a statue holding a rose in his honor, which symbolized his artistic surgical endeavors. However, dogmatists in the contemporaneous prevailing religious faction had him excommunicated. They thought that Tagliacozzi was “imperiously interfering with the handiwork of God.” The religious faction even exhumed his body from a hallowed church burial site and reinterred him in unconsecrated grounds. For the next 2 centuries there was very little advancement in the field of rhinoplasty.

Medical Tourism in Iran

Rhinoplasty in Iran

Breast augmentation in Iran

Butt Lift in Iran

Ear Surgery in Iran

 

THE REAWAKENING PERIOD

In 1794, B. Lucas, an English surgeon who was working in India reported to have witnessed the reconstruction of a cutoff nose by using a pedicled forehead flap. The operation was performed by a man from the caste of the tile and brick makers in Poona, near the Indian coast. Lucas sent a letter regarding the operation to the Gentleman’s Magazine of London for the October edition. The account was read by Joseph Carpue, a British surgeon at York Hospital in Chelsea, England. Carpue was piqued by the concept and practiced the procedure on cadavers for approximately 20 years. Finally in 1814, he performed nasal reconstructions on 2 patients. He published the cases in an illustrated monograph where it gained great recognition among European surgeons. Interestingly enough, though Carpue was elected as a Fellow to the Royal College of Surgeons, he was passed over by the same Royal College to sit on their Council. He was disdained by his own contemporaneous professional colleagues.4,5 Carl Ferdinand Von Graefe in 1818 published his famous work, Rhinoplastik. It had 208 pages and 55 citations. Although he was born in Warsaw, he was educated in Germany and was considered German. In his book, he noted 3 different surgeries: the Indian technique with the forehead flap; the delayed Italian method of Tagliacozzi; and the third, he called the German method that entailed a free graft from the arm. In addition to his rhinoplastic work, he wrote original articles on such subjects as blepharoplasty and cleft palate repair. To many, he is considered the founder of modern plastic surgery. His son became the leading ophthalmologist in Europe. In 1840, Von Graefe, the father, died while performing an operation.4,5 Johann Friedrich Dieffenbach succeeded Von Graefe in Berlin with his professorial titles. Dieffenbach was one of the first surgeons to use local anesthesia, and at a later date, ether anesthesia, while performing his rhinoplastic techniques. His book, Operative Surgery (1845), discusses nasal reconstruction for over 100 pages. He also discussed the endonasal or the subcutaneous approach to nasal surgery. Some consider him the greatest plastic surgeon of his era.4,5 Nasal reconstruction was first performed in the United States by Dr J.M. Warren in Boston, Massachusetts, in the late 1830s. He had previously visited Von Graefe. Dr Warren was related to John Collins Warren, also of Boston. It was the latter Warren who painlessly removed a tumor on a patient’s neck with the aid of ether anesthesia administered by William Thomas Green Morton, a dentist, at the Massachusetts General Hospital on October 6, 1846. Morton said to Warren, after administering the ether general anesthetic to the proper surgical depth, his famous words, “Doctor, your patient is ready.” On finishing the procedure, Warren expounded to the surgical attendees present, with his also famous remark about Morton’s ether anesthetic, “Gentlemen, this is no humbug.”9,10 Concurrently and fortuitously, 2 additional discoveries were made that had great impact in broadening the interests of both the surgical and lay communities with regard to the functional and aesthetic advancement of rhinoplastic procedures. They were the discovery of the antiseptic qualities of carbolic acid (phenol) by an English surgeon and the local anesthetic qualities of cocaine. Joseph Lister in 1867 published his seminal and patient-altering paper on antiseptic principles to reduce infection. The paper was based on the concepts of Louis Pasteur. Lister found that the use of carbolic acid (phenol) greatly mitigated wound infection. As a professor of surgery at the University of Glasgow, he instructed surgeons under his charge to wash their hands before and after operations with a 5% carbolic acid solution and to wear clean gloves. Instruments and the operating theater were sprayed with the same solution. The rate of hospital infections dramatically dropped.14 In 1455, the Spanish explorer Augustin de Zarate discovered Peruvian coca. However, it wasn’t until approximately 400 years later (1884) that Spanish soldiers while in South America as conquistadors became familiar with the native use of the coca leaf. When brought back to Europe, it was chemically refined into cocaine, which had local anesthetic properties.15 One could readily conjecture that an operative procedure that increased the aesthetic value of the face, was relatively comfortable and free of pain for the patient, and in addition, greatly mitigated the chances of infection might gain a potential universal audience. And so it did! In 1875, William Adams, a dentist, published an article on nasal fracture reduction. He divided the fractures into those associated with bone and those associated with cartilage. Although for one of his patients, initial treatment was initiated at 6 years postfracture, his treatment was earlier and more aggressive than most in an effort to avoid potential fracture-related traumatic deformities. He also fashioned forceps to reduce the fractures that are not unlike those that are still in use today. His concept of external support is also contemporaneous.16 Dr John Orlando Roe (1848–1915) was an otolaryngologist from Rochester, New York. In 1887, he published an article regarding a “pug nose.” (A pug nose is one with large lower lateral cartilages plus or minus a concavity of the dorsum.) He performed the surgery for purely aesthetic reasons, a literature first. Besides, he performed the surgery from an intranasal approach, also a first. However, within the same article, Roe divided the nose into 5 main morphologic classes. One of the classifications was flagrantly anti-Semitic with regard to its implications and the manner in which it was further defined. This classification was probably based on the notations of Robert Knox, a period physiognomist. (For the reader, physiognomy has no scientific basis.)17–20 Four years later, in 1891, Roe published a second seminal paper on the correction of angular nasal deformities with great emphasis on the subcutaneous approach. (Dieffenbach, however, is given credit for first introducing the endonasal approach in 1845.) In addition to working from the interior of the nose, he routinely used external and internal splints to keep his postoperative results in their best aesthetic position. Also, he was one of the first to use presurgical and postsurgical photographs to illustrate his results. Some call him the true father of aesthetic rhinoplasty. Dr Robert F. Weir (1838–1927) is associated with several innovations and modifications in the performance of nasal surgery. For example, he altered Adam’s forceps to make them thinner and more delicate for the reduction of fractures. In what he termed an “osteoplastic operation,” he used an osteotome to make his fracture reductions “more even.” He used osteotomes and forceps to divide the nasal bones in the midline. He also infractured them at their juncture with the maxillae to narrow bone width along with simultaneous elevation of the bony dorsum. However, Weir is probably best known for his attempts to correct nasal dorsum deformities. He inserted the sternum of a freshly killed duck to augment a saddle nose. In retrospect, as one might expect, the heterogeneous graft lasted but a few weeks. His use of a platinum strut was somewhat more successful. 21,22 However, it was James Israel, who in 1896 successfully augmented the saddle nose with a tibial graft.23 Weir innovatively removed a wedge of the lower lateral cartilages at their facial angle to reduce interalar width and thus created a greater morphologic symmetry. The latter operation is still widely used and bears his name.

ALONG COMES THE WUNDERKIND

Dr Jacques Lewin Joseph (1865–1934) was born and grew up in Ko¨ nigsberg, Prussia (now, Kaliningrad, Russia). He obtained his doctorate in medicine in 1890 at the University of Leipzig, practiced in Berlin for a short period of time, and then studied orthopedic surgery at the J. Wolff Clinic in Berlin. He published his first article on reduction rhinoplasty using an external approach. He later acknowledged that Roe, Weir, and Dieffenbach had preceded him with similar work. Although Joseph performed plastic procedures on other parts of the body, he is most recognized for devising nasal operations and designing inventive new instruments, which he used to achieve his techno-anatomic goals. Joseph developed a great ability to conceptualize a reshaped anatomically deficient entity and the biomechanical approach to achieve his wellthought- out goals. As an orthopedist, and for his era, he understood how to transplant osseous tissue like bone from the tibia to the dorsum to correct saddle nose deformities. He studied and classified several nasal deformities and devised individualized procedures for their correction on a scientific basis (unlike physiognomy). His artistic drawings and meticulous operative details definitively established him as a rhinoplastic surgeon par excellence. Later, he insisted that photographs and plaster molds be taken for every patient. Joseph developed a great many instruments to use for various facetsofhisdevised correctiveprocedures. For example, for rhinoplasty, he designed various saws to reduce nasal bony and cartilaginous hypertrophies and to have greater control over the lineal separation of lateral nasal fractures for width reduction. He also designed special scalpels for cartilage modification to increase aesthetic contour, external nasal splints, and headbands to hold repaired deviated septa in place. Although Dieffenbach, Roe, and Weir first discussed changes from a subcutaneous approach, it was Joseph, who for years taught and wrote scientific articles concerning the aesthetic reduction and augmentation involving rhinoplastic procedures. Even today, many people believe thatmostrhinoplastic operations are just variations of Joseph’s body of work. One might say that rhinoplasty was born “fully grown” with the emergence of his scientific articles and books. Joseph died under enigmatic circumstances, while fleeing Hitler’s Nazi Germany, in Czechoslovakia in 1934.5,24–32 Some who attended Joseph’s courses or were contemporaneous with Joseph or his pupils were such great historical names as Gustave Aufricht,33 Joseph Safian,34 Jacques Maliniac,35 John M. Converse,36 Abe Silver (Silver WE, Abe Silver, personal communication, 2010), and Sam Foman,37 who in turn gave courses that included Maurice Cottle38 and Irving Goldman.39 It has also been said that Joseph was a bit quirky. During one of his courses, his instruments were placed on an operating room table that was completely covered with a towel so that no one could discern their design. He operated gloveless. Instruments were passed to him covertly from under the towel. One night while taking one of Joseph’s courses, Foman persuaded one of Joseph’s assistants to show him his instruments. And with lightning speed, Foman drew them all. When Foman returned to the United States, he had a friend from the Klink instrument company manufacture the instruments. He later sold them at his rhinoplasty courses (Silver WE, Sam Foman, personal communication, 2010).40 Cottle and Goldman, in due course, gave their own rhinoplastic courses that influenced hundreds of future rhinoplastic surgeons. Many of these gifted surgeons created alterations and some newer rhinoplastic procedures (dome division, elevation of the upper lateral cartilages, additional instrumentation, greater aesthetic forehead flaps, improved postoperative splint dressings, and many other modifications). However, the basic concept came to them, ‘fully grown’. In addition, one cannot exclude other such names as Sir Harold Gillies,40 V.H. Kazanjian,41 D.R. Millard,42 and J.E. Sheehan.

A MAJOR REASSESSMENT

For some surgeons, the endonasal approach had shortcomings. For example, in most instances, surgeons knew from their own formal education, or through observation of other surgeries, researched articles, and case repetitions the subcutaneous disproportionate anatomic morphology of nasal deformities. However, by not being able to directly visualize a problem in situ, the ability to intensely comprehend the anatomic nature of the problem and then treat was compromised. For example, as much subcutaneous fatty and connective tissues (the so-called superficial musculoaponeurotic system layer) as possible might not be removed from above a surgerized dome because of lack of total visualization. This, in turn, might compromise the amount of the final aesthetic acuteness of clarity and shape of tip bulbosity. Thus, a great result might have been diminished to a good result. Another example might be a visualized actual comparison of the reduction right and left lower lateral cartilages after surgery, but before closure, relative to height, width, symmetry, convexity, and so on. On a similar note, Ellsworth Toohey once said in Ayn Rand’s The Fountainhead, “The enemy of excellence is good.”44 Good is not what we want. Then, in 1970, in Zagreb, in the former Yugoslavia, at a meeting of the American Academy of Facial Plastic and Reconstructive Surgery,45 a modestly known Yugoslavian surgeon, Ivo F. Padovan, from the meeting city itself, presented a paper on the “The external approach to rhinoplasty.”46 His 10-minute presentation was based on 400 of his own cases and 500 cases of his mentor, Ante Sercer.47 Both their observations were based on the work of Aurel Rethi of Budapest.48 An attendee at the meeting, Dr Robert Simons noted, “A revolutionary shot in the rhinoplasty world had been fired, but it was neither heard nor appreciated immediately.”49 However, William Goodman, from Toronto, Canada, who was also in attendance at Padovan’s lecture, returned home to begin performing the “external approach” for several nasal deformities. He refined the “gull-wing” incision with a resultant greater patient acceptance. Goodman published several articles regarding the positive, aesthetic, and structural outcomes that he was achieving.50–52 As fate would have it, at around the same time, a young Canadian otorhinolaryngologist, Peter Adamson, who was very much in tune with Goodman’s external approach, began a facial plastic fellowship with Jack Anderson of New Orleans. During this time, Anderson had a renowned reputation for being one of the best known and most well-respected facial plastic surgeons with an unquenchable fire in his belly for the art of rhinoplastic surgery. In addition to these qualities, he was also considered to be a great teacher.53 Before the Adamson fellowship, Anderson thought that he could do basically anything endonasally that one could do via an open method. He was very passionate about nasal surgery but was not afraid to try something different if he thought it was biologically just. His practice associate at the time was Calvin Johnson, a well-known facial plastic surgeon in his own right. With Adamson’s history with William Goodman and Anderson’s scientific inquisitiveness, they started performing external approach rhinoplasties using the midcolumellar approach. In an assessment paper on open rhinoplasty, Anderson, Johnson, and Adamson performed several hundred open procedures, and one of their significant conclusions was that they could not find fault with any surgeon who chose to perform all of their rhinoplasties via the open approach.54,55 There have been several alterations in the procedure but nothing that has altered the basic rhinoplastic surgery as postulated by Joseph. Newer alloplastic materials have been used in augmentation settings.56 Some newinstrumentation was developed that made the shaping of cartilage and osseous contouring more effective. However, it is of interest to note, that one of the most inventive rhinoplastic instrument designers who also wrote and lectured on rhinoplastic surgery was a general medical practitioner and not a surgeon per se.57–59 Rhinoplasty has come a long way, and along the way many people have benefited from the many surgeons from antiquity to the present. These surgeons have tried to give their patients a more attractive face by altering the one physical anatomic structure that one usually notices first.

NOW COMES ORAL AND MAXILLOFACIAL SURGERY

And with this wonderful circuitous medical history, how did oral and maxillofacial surgery, a dentally based specialty, become a player? During the early part of the 1980s, after regular American Association of Oral and Maxillofacial Surgeons (AAOMS) board meetings, evening blue sky sessions occurred, involving board and staff members. Nagging questions continued to arise relative to just what was our surgical scope. Had we reached our zenith? Was our surgical breadth already defined and finalized by us or, even worse, by others. Concurrently, at annual and midwinter meetings, orthognathic surgery programs were almost always assured that lecture halls would be filled to capacity. The expanded version of orthognathic surgery (or orthodontic surgery as it was then called) was developed to a great degree by European colleagues during the post–World War II era because of a lack of orthodontists and orthodontic materials. Since they could not consistently rely on orthodontic care to aid in the treatment of the many orofacial skeletal deformities, they ingeniously devised technical intraoral methods to operate simultaneously on both the maxillae, the mandible, and their segmental components. Later, definitive biologic credence for these procedures was established by Bell and Levy in 1970 with rhesus monkey angiographic studies.60 Therefore, it was obvious that facial aesthetics in the form of facial bone reconstruction was paramount in the minds of several members of the orthognathic surgical community. Serendipitously, for some, pieces of an arcane puzzle started to swirl about during this period. The author’s own awareness started when a 17-yearold patient was seen for facial aesthetic evaluation. The patient had recently had orthodontic treatment that involved 4 first bicuspid extractions. If one were to evaluate her postorthodontic models alone, the tooth alignment and achieved occlusion were excellent. However, if one assayed the face, in its entirety, it became obvious that the lower onethird of the face was severely “dished.” As oral and maxillofacial surgeons (OMS), we are well aware that a potential treatment of bimaxillary horizontal retrusion is maxillary and mandibular advancement surgery. This surgery is usually accompanied with a genioplasty. The concept was presented to the patient’s family, and the surgeries were successfully performed. Although the osteotomy sites began to heal in their normal manner and the facial edema subsided, to even a casual observer the patient’s previously veiled nasal deformity became the focal point of her face. The patient’s family sought the services of a rhinoplastic surgeon. The surgery was performed and I saw the patient several weeks later. She had become a swan! I was stunned. I thought that out of all the facial surgeries recently performed on her, the nasal alterations made, by far, the greatest significant impact in her overall facial aesthetics. Although, at the time OMS were performing rhinoplasties to only the slightest moderate degree, the thought occurred that as OMS, we operate lateral to the nose, inferior to the nose, above the nose, and on occasion, within the nose. Why should we not perform aesthetic operations on the nose in combination with other facial procedures, or as a stand-alone procedure? After all, we are OMS. And the nose is clearly in the center of the maxillofacial region. Why not? But who would teach an oral surgeon, and better yet, one without a medical degree? Enter, Dr William (Billy) Silver, an otolaryngologist by formal post–medical school residency training. After living in the same area for several years, Dr Silver and I had become geographic friends who shared ideas, techniques, generalized information, and stories about people and events in our respective specialties. Dr Silver’s brother was an orthodontist, his father, a general dentist, and his uncle, Abe Silver, a rhinoplastic surgeon. His uncle, Abe, was part of New York’s well-known Mount Sinai Hospital’s rhinoplastic teaching group along with Irving Goldman. Dr Goldman was the creator of the famous nasal dome division for greater tip definition, which bears his name (the Goldman tip). Dr Billy Silver received additional training after his formal otorhinolaryngology residency by spending much time with Drs Richard Webster of Boston, Jack Anderson of New Orleans, and Maury Parks of Los Angeles. This was the route taken by many future facial plastic surgeons even before there was an official subspecialty of facial plastic surgery and, for that matter, facial plastic fellowships. These members were indeed the pioneers of this new specialty. It was not an easy row to hoe logistically, politically, or financially for these potential members of the newest specialty in the head and neck region. There was a great deal of opposition to the formation of the specialty from anatomically regional medical competitors.61 In fact, $1.2 million was levied in a lawsuit that weighed against the Georgia Society of Plastic Surgeons regarding the professional competency of facial plastic surgeons.62,63 With this background in mind, a telephone call was made to Dr Billy Silver. When asked if he were sitting down, his answer was yes. “Billy, I would like you to teachmehow to do rhinoplasties.” There was a pause on the phone, which seemed to me like 1 hour but was actually just momentary. I thought he had fallen off the chair, fainted, or both. At the end of this pregnant pause, he answered with resolve in his voice stating that he would be more than delighted to teach me. He mentioned a book that he wanted me to read.64 He also asked me to call his receptionist for a list of rhinoplasties that he had scheduled so I could initially observe the mechanics and instrumentation. And so it began. To say the least, it was exciting! I spent time with him that year and with other surgeons, while also attending several meetings.65 The 1988 AAOMS Midwinter meeting on the topic of Esthetic Considerations in Oral and Maxillofacial Surgery held in Tucson, not an easy place to get to,was up to that time the largestmidwintermeeting everattended.Thetopicsincludedliposuction, facial augmentation, rhinoplasty, cheiloplasty, and others. The American Academy of Cosmetic Surgery was a fledgling organization devoted to cosmetic surgery. The academy consisted of a group of professionals in search of a platform to share and add to their cosmetic knowledge. I attended a few meetings and then submitted the required number of cases to become a full member. They were good to OMS. Academy presidents such as Julius Newman, Howard Tobin, and Tom Alt opened their offices to academy members for the observation of patient treatment. Their only criterion was an interest in cosmetic surgery. It was also there that I had the privilege of meeting Richard Webster while I was a member of the academy board. It was his philosophy that every specialty brings something unique to the cosmetic surgery table. Early on, for the OMS who was interested in performing cosmetic surgery, the academy was like a home away from home, but never forgetting that home was truly the AAOMS. Some books on rhinoplasty were somewhat confusing to me until I read Open Structure Rhinoplasty by Calvin Johnson and Dean Toriumi.66 The book was transforming. I read it, reread it, made flash cards, and then I was fortunate to spend a week in Dr Johnson’s office. Sheen’s 2-volume text is also a giant in the rhinoplastic literature.67 After about a year, I started to perform rhinoplastic procedures myself. First, dorsal hump removals and gradually into the more intricate dome and lateral osteotomies. These were performed, at first with orthognathic surgeries and later as standalone procedures. Over a period of time, but gradually, the local hospital staff credentialing committees were won over. Patients who formerly underwent rhinoplasty and orthognathic surgery asked if facelifts, eyes, and peels were in our specialties preview. And then the process started all over again. During this period of time, representatives of the AAOMS met with the American Board of Oral and Maxillofacial Surgery. The 2 national organizations updated the definition of the specialty to include the treatment of facial aesthetic defects. The house of delegates of the American Dental Association later ratified this change. Although some dental boards were recalcitrant in accepting the change because of several frivolous reasons, a significant number of individual states changed their definition with rapidity to coincide with the more realistic definitions of our national organizations. So we can say with assurance, that rhinoplasty and oral and maxillofacial surgery are now tightly interwoven in the future of the specialties scope. And in fact, can any other specialty routinely surgically alter the maxillae, advance it anteriorly, reduce its height, increase its height, alter the mandibular morphology, make it longer or shorter, and so forth? The same could be said for the chin and then a rhinoplasty could be performed to balance out the aesthetics of the face. And lastly, one can also state that the services of those that also perform reconstructive facial plastic surgery is still a very much needed surgical therapy.

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