FOREWORD

Paul Tessier had the idea for this monograph in 1999, after reading a report on a symposium on biomaterials and bone substitutes1 in which there was considerable discussion of various alloplastic materials but very little discussion of what he believed was the very best bone substitute, an autogenous bone graft. Craniofacial surgery exists today as a separate surgical discipline because of the pioneering work of Paul Tessier. Indeed, the main difference between the successful Le Fort III-type osteotomies performed by Tessier in the late 1950s and early 1960s and the earlier, similar operation performed by Sir Harold Gillies was that Tessier placed bone grafts in his surgically created gaps and had a stable result, whereas Gillies did not and had a relapse requiring a subsequent “camouflaging” operation. Gillies’ case is presented in brief in Gillies and Millard.2 The patient appears to have a mild Crouzon syndrome, and Gillies performed what was certainly the first Le Fort III osteotomy in 1942. There was a significant relapse, and in 1949 Gillies reoperated on the patient. With Hugo Obwegeser3 as the assistant, he performed an orbital expansion and placed ox cartilage grafts on the infraorbital rims and nose, and did nothing for the malocclusion. Of the case, Gillies and Millard said, “In light of subsequent experience, even this small loss could have been avoided by packing chip grafts into the strategic osteotomy chinks.” The “classic” operations of craniofacial surgery–-the Le Fort III-type osteotomy, the correction of orbital hypertelorism and other orbital dystopias, the correction of posttraumatic enophthalmos and other sequelae of facial fractures, the correction of the facial difference of Treacher-Collins-Franceschetti syndrome, and the monobloc frontofacial advancement–-were all developed by Tessier. All of these operations relied on the use of autogenous bone grafts, and all continue to be used successfully as he described them. At just about the time Dr. Tessier retired from active surgical practice, a new mode of treatment came on the scene: distraction osteogenesis. He welcomed this new method of treatment enthusiastically, and in fact gave it an acronym that has stuck: DOG. Distraction osteogenesis has extended the frontiers in that many conditions, such as hemifacial microsomia, the Pierre Robin anomalad, and midface deficiency, can be treated earlier and without the need for bone grafting. However, distraction osteogenesis has not rendered orthognathic surgery obsolete, as some had predicted, nor has it changed the indications for most of the “classic” craniofacial procedures. Knowing how to harvest an autogenous bone graft is still important, and many of us are astonished when a new craniofacial fellow shows up for service having just completed an entire plastic surgery residency in which he or she did not see a single autogenous bone graft taken. Bone morphogenic protein-2 has received U.S. Food and Drug Administration approval for use in spine surgery and for alveolar bone grafts. It may help autogenous bone form without a bone graft in some areas, and it may help increase the take of free bone grafts. We are enthusiastic about its possibilities. It is still very expensive, and it is unlikely that it will replace the need for autogenous bone grafts. In the time that has passed since Gosain and Persing’s 1999 publication,1 which was the impetus for this entire work, another publication