The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Editorial Historical Classics This issue of Laryngoscope celebrates two classic articles that challenged underlying assumptions and fundamentally altered our approaches to patient care in facial plastic and reconstructive surgery. The Laryngoscope has published many such seminal manuscripts, and these choices naturally reflect my professional life story. Rather than relying on citation indices, I have selected these two articles on the strength of their educational impact on subsequent generations of otolaryngologists. Goodman and Charbonneau’s “External Approach to Rhinoplasty”1 was presented at the Seventy-Seventh Annual Meeting of the Triological Society in Palm Beach, Florida, on April, 25, 1974, and published by The Laryngoscope later that year. Its impact resounded like a thunderclap across the field of facial plastic surgery. For the first time in a US journal, a respected academic surgeon challenged the supremacy of Jacques timehonored endonasal approach to rhinoplasty. Building on the groundbreaking work of Rethi,2 Sercer,3 and Padovan,4 and on his own published experience,5 Goodman described open rhinoplasty’s “great sense of control and satisfaction operating under direct vision” (page 2200) and posited that the external approach “seem[ed] to be the procedure of choice for many problems” (page 2195). Over the course of the subsequent 2 decades, a healthy debate over the endonasal and external approaches would rage across our specialty. My aha! moment occurred in 1990, when I discovered Goodman’s technique through Johnson and Toriumi’s lavishly illustrated book, Open Structure Rhinoplasty.6 Maneuvers in rhinoplasty surgery that seemed puzzling became clear when exposed, as it were, to direct vision. New techniques for the preservation of tip support, the reconstitution of the nasal valve, and the precise application of cartilage grafts became accessible. More importantly, however, the learning curve for me and for many rhinoplasty surgeons dramatically eased to the clear benefit of our patients. Over the years, both endonasal and open rhinoplasty surgeons embraced the field’s shift from an emphasis on cosmetic results to an insistence on functional outcomes. Goodman’s work catalyzed a revolution in education that reverberates to this day in the attention afforded not only to the before and after but also the how and why of rhinoplasty. In 1991, Urken et al. legitimized microvascular free-flap reconstruction by publishing a seminal outcome study comparing oral function in reconstructed versus nonreconstructed patients.7 Prior to “Functional evaluation following microvascular oromandibular Laryngoscope 125: July 2015
reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients,” the majority of reports on free flap transfers had focused on the success and reliability of the procedures rather than on the recovery of function. As a result, microvascular reconstruction was slow to gain a foothold within academic departments of otolaryngology across the country, many of whom asked plastic surgery or hand surgery colleagues to perform these reconstructions for their head and neck patients. By comparing a group of 10 reconstructed and 10 nonreconstructed segmental hemimandibulectomy patients with tests assessing their overall well-being, cosmesis, deglutition, oral competence, speech, and dental rehabilitation, as well as using objective measures of chewing performance, Urken’s team was able to demonstrate “a clear advantage for the reconstructed patients in almost all categories.” Reconstructed patients were able to resume employment and social activities with “a level of function and cosmesis that more closely matched their pre-disease state” (page 935). Moreover, reconstructed patients were able to achieve these outcomes more quickly and at a lower cost of hospitalization than their unreconstructed counterparts. Over the course of the ensuing decade, in response to this and similar publications, otolaryngology departments would shift their focus from outsourcing microvascular reconstruction to recruiting otolaryngology-trained microvascular surgeons tasked with developing multidisciplinary teams to rehabilitate patients following ablative head and neck surgery. The ultimate beneficiaries of this educational shift would prove to be our patients, who are now served by teams of dedicated surgeons, nurses, speech/swallowing specialists, and other hospital personnel committed to restoring their quality of life. Both classic The Laryngoscope articles pivoted on established educational dogmas to chart new paths in patient care. Forty years ago, few otolaryngologists opened the nose to treat cosmetic deformities and functional deficits. Twenty years ago, few otolaryngologists saw firsthand how free-flap transfers could restore dignity and capacity to head and neck cancer survivors. Today, the professional life stories of all our graduates include training in these fundamental techniques. More significantly, our patients’ life stories have been brightened by our specialty’s journey along these novel, rewarding avenues of endeavor.
EDMUND A. PRIBITKIN, MD Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Pribitkin: Editorial
1503
BIBLIOGRAPHY 1. Goodman WS, Charbonneau PA. External approach to rhinoplasty. Laryngoscope 1974;84:2195–2201. 2. Rethi A. Operation to shorten an excessively long nose. Revue de Chirurgie Plastique, No 2, Oct. 1934. 3. Sercer A, Mundnich K. Plastiche Operationen an der Ohrmuschel. G. Rhieme Verlag, Stuttgart, Germany, 1962. 4. Padovan L. External approach in rhinoplasty (Decortication). Sump. ORL Lug. 1966;3–4:354–360.
Laryngoscope 125: July 2015
1504
5. Goodman WS. External approach to rhinoplasty. Can J Otolaryngol 1973; 2:207–210. 6. Johnson CM, Toriumi DM. Open Structure Rhinoplasty. New York, NY: WB Saunders; 1990. 7. Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope 1991;101:935–950.
Pribitkin: Editorial
Rhinological and Otological Society, Inc.
Editorial Historical Classics This issue of Laryngoscope celebrates two classic articles that challenged underlying assumptions and fundamentally altered our approaches to patient care in facial plastic and reconstructive surgery. The Laryngoscope has published many such seminal manuscripts, and these choices naturally reflect my professional life story. Rather than relying on citation indices, I have selected these two articles on the strength of their educational impact on subsequent generations of otolaryngologists. Goodman and Charbonneau’s “External Approach to Rhinoplasty”1 was presented at the Seventy-Seventh Annual Meeting of the Triological Society in Palm Beach, Florida, on April, 25, 1974, and published by The Laryngoscope later that year. Its impact resounded like a thunderclap across the field of facial plastic surgery. For the first time in a US journal, a respected academic surgeon challenged the supremacy of Jacques timehonored endonasal approach to rhinoplasty. Building on the groundbreaking work of Rethi,2 Sercer,3 and Padovan,4 and on his own published experience,5 Goodman described open rhinoplasty’s “great sense of control and satisfaction operating under direct vision” (page 2200) and posited that the external approach “seem[ed] to be the procedure of choice for many problems” (page 2195). Over the course of the subsequent 2 decades, a healthy debate over the endonasal and external approaches would rage across our specialty. My aha! moment occurred in 1990, when I discovered Goodman’s technique through Johnson and Toriumi’s lavishly illustrated book, Open Structure Rhinoplasty.6 Maneuvers in rhinoplasty surgery that seemed puzzling became clear when exposed, as it were, to direct vision. New techniques for the preservation of tip support, the reconstitution of the nasal valve, and the precise application of cartilage grafts became accessible. More importantly, however, the learning curve for me and for many rhinoplasty surgeons dramatically eased to the clear benefit of our patients. Over the years, both endonasal and open rhinoplasty surgeons embraced the field’s shift from an emphasis on cosmetic results to an insistence on functional outcomes. Goodman’s work catalyzed a revolution in education that reverberates to this day in the attention afforded not only to the before and after but also the how and why of rhinoplasty. In 1991, Urken et al. legitimized microvascular free-flap reconstruction by publishing a seminal outcome study comparing oral function in reconstructed versus nonreconstructed patients.7 Prior to “Functional evaluation following microvascular oromandibular Laryngoscope 125: July 2015
reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients,” the majority of reports on free flap transfers had focused on the success and reliability of the procedures rather than on the recovery of function. As a result, microvascular reconstruction was slow to gain a foothold within academic departments of otolaryngology across the country, many of whom asked plastic surgery or hand surgery colleagues to perform these reconstructions for their head and neck patients. By comparing a group of 10 reconstructed and 10 nonreconstructed segmental hemimandibulectomy patients with tests assessing their overall well-being, cosmesis, deglutition, oral competence, speech, and dental rehabilitation, as well as using objective measures of chewing performance, Urken’s team was able to demonstrate “a clear advantage for the reconstructed patients in almost all categories.” Reconstructed patients were able to resume employment and social activities with “a level of function and cosmesis that more closely matched their pre-disease state” (page 935). Moreover, reconstructed patients were able to achieve these outcomes more quickly and at a lower cost of hospitalization than their unreconstructed counterparts. Over the course of the ensuing decade, in response to this and similar publications, otolaryngology departments would shift their focus from outsourcing microvascular reconstruction to recruiting otolaryngology-trained microvascular surgeons tasked with developing multidisciplinary teams to rehabilitate patients following ablative head and neck surgery. The ultimate beneficiaries of this educational shift would prove to be our patients, who are now served by teams of dedicated surgeons, nurses, speech/swallowing specialists, and other hospital personnel committed to restoring their quality of life. Both classic The Laryngoscope articles pivoted on established educational dogmas to chart new paths in patient care. Forty years ago, few otolaryngologists opened the nose to treat cosmetic deformities and functional deficits. Twenty years ago, few otolaryngologists saw firsthand how free-flap transfers could restore dignity and capacity to head and neck cancer survivors. Today, the professional life stories of all our graduates include training in these fundamental techniques. More significantly, our patients’ life stories have been brightened by our specialty’s journey along these novel, rewarding avenues of endeavor.
EDMUND A. PRIBITKIN, MD Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A. Pribitkin: Editorial
1503
BIBLIOGRAPHY 1. Goodman WS, Charbonneau PA. External approach to rhinoplasty. Laryngoscope 1974;84:2195–2201. 2. Rethi A. Operation to shorten an excessively long nose. Revue de Chirurgie Plastique, No 2, Oct. 1934. 3. Sercer A, Mundnich K. Plastiche Operationen an der Ohrmuschel. G. Rhieme Verlag, Stuttgart, Germany, 1962. 4. Padovan L. External approach in rhinoplasty (Decortication). Sump. ORL Lug. 1966;3–4:354–360.
Laryngoscope 125: July 2015
1504
5. Goodman WS. External approach to rhinoplasty. Can J Otolaryngol 1973; 2:207–210. 6. Johnson CM, Toriumi DM. Open Structure Rhinoplasty. New York, NY: WB Saunders; 1990. 7. Urken ML, Buchbinder D, Weinberg H, et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients. Laryngoscope 1991;101:935–950.
Pribitkin: Editorial
