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Innovations and Contributions to Craniofacial Surgery in Japan

Fujino, Toyomi, MD, FACS

doi: 10.1097/SCS.0000000000004839
Original Articles

I look back at my decades in the field of plastic and reconstructive and craniofacial surgery, knowing I was the driving force behind its inception in Japan. However, behind me in turn, supporting me, teaching me, and encouraging me during my formative plastic surgery years in the United States and Europe have been many of the true giants in this field, and I will always accord them my total respect and deepest gratitude. Without their knowledge and technique, which they selflessly taught me and my peers, I would certainly never have been able to accomplish so much in the field of plastic and reconstructive surgery, and in particular, craniofacial surgery.

Department of Plastic and Reconstructive Surgery, Keio University, Tokyo, Japan.

Address correspondence and reprint requests to Toyomi Fujino, MD, FACS, Department of Plastic and Reconstructive Surgery, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan; E-mail: fujinotsr@polka.ocn.ne.jp

Received 30 May, 2018

Accepted 16 June, 2018

The author reports no conflicts of interest.

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FOUNDING THE JAPANESE SOCIETY OF CRANIOMAXILLOFACIAL SURGERY

The genesis and growth of craniofacial surgery in Japan is quite long, beginning in Yokosuka, moving to inspiration (with a lot of perspiration) in many locations in the USA and a brief interlude in France, and finally coming to fruition in Keio University Hospital in Tokyo. Perhaps the real beginning, if there is 1 single event that can be identified as the starting point of craniofacial surgery in Japan, might well be my successful performance of the first case worldwide of facial hemiatrophy, which I successfully treated with combined techniques of craniofacial and microvascular surgery on March 25 and May 21, 1974 (Fig. 1 ).

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This successful procedure planted the seed in my mind to establish the Japan Society of Craniofacial Surgery. The first Congress of the International Society of Craniofacial Surgery was held in La Napoule, France, in 1985 with Dr. Daniel Marchac as organizer and Dr. Paul Tessier as honorary president. After the presidential dinner in La Napoule, the Japanese participants gathered that night and I proposed to them the establishment of the Japan Society of Craniofacial Surgery.

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BECOMING A BOARD CERTIFIED US PLASTIC SURGEON IN 1965

In the years of the 1950s, there was a trend among the young students to go the United States to study with the aid of the Fulbright Travel Scholarship in Medicine—the most generous nonimbursement medical grant in the USA. But for me in order to make this dream come true, it was absolutely mandatory for me to master English communication. So, I moved to Yokosuka while I was a medical student, so I could take private lessons from an interpreter at the US Naval Base. I was successfully accepted as one of 6 interns at the US Naval Hospital from April 1957 to March 1958. In August 1957, 10 prominent American professors in various medical fields visited and lectured at the USNH. One of them was Professor Herold Griffith (Fig. 2) of the Department of Plastic Surgery at Northwestern University. His lecture impressed me so much that I made up my mind to be a plastic surgeon soon after I heard him speak. It may be a synchrodestiny that 60 years later (2018), Professors of plastic surgery at Northwestern University (Gosain, Yamada) (Figs. 3 and 4) will organize World Society of Simulation Surgery that I founded.

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With a recommendation from a Wisconsin graduate, a lieutenant stationed at the USNH in Yokosuka, I was accepted as a rotating intern at the Wisconsin University Hospital. On June 18, 1958, I was one of 30 Fulbright medical fellows from Japan who sailed from Yokohama to San Francisco on the President Wilson, a ship of the American President Line. After 7 days, we arrived at Honolulu in Hawaii and disembarked at Aloha Tower as our first steps in America. The local people welcomed us warmly by serving various kinds of tropical fruits, which we had never tasted before in economically poor postwar Japan. After a half-day stay in Honolulu, the President Wilson sailed for the US mainland. After passing under the Golden Gate Bridge, we finally arrived at the Pier 72 in San Francisco on July 28, then flew in a 4-propeller airplane to Chicago, where we changed to a second smaller Air Force plane bound for Madison in Wisconsin. Such a long journey was the first of its kind in my life, and most smooth and I loved it.

June 30, 1958 was an orientation day for the new interns at the University of the Wisconsin Hospital. Among the interns, I was only one who was free to choose my first month's service, and without hesitation I elected to enter the hospital's plastic surgery service. Professor Frank D. Bernard (Fig. 5), chief of the Plastic Surgery Department and Dr W.W. Wiviott, chief resident in plastic surgery, kindly taught me about all general plastic surgery including cleft lip and palate repair, and skin grafting using the Padgett Hood Dermatome. In turn, I informed Professor Torai Iwahara, the chairman of orthopedic surgery at Keio University School of Medicine in Tokyo in detail about all my experiences. Professor Iwahara was the one of the founding members of the Japan Society of Plastic Surgery, and he was so happy with my progress that he encouraged me to finish a 2-year plastic-surgery residency and encouraged me to be a plastic surgeon in United States and return home to establish the Department of Plastic Surgery in 1963 (Fig. 6).

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However, passing the examination of the Educational Commission for Foreign Medical Graduates (ECFMG), whose level is equivalent to the national examination of medical practice in the United States, became mandatory for foreign medical graduates. In addition, the American Board of Plastic Surgery changed its rule regarding an extension of prerequisite general surgery residency from 2 years to 3 years, requiring an additional year of general surgery residency. Therefore, I was obliged to take my second-year plastic surgery residency somewhere else, and Professor Bernard kindly arranged for me to go to the Department of Head and Neck B and Reconstructive Surgery at the Roswell Park Memorial Institute (RPMI) in Buffalo, New York in 1963 Dr. Stanley F Hoffmeister was the chief.

In September of that year, the International Congress of the International Confederation of Plastic, Reconstructive and Aesthetic Surgery was held at Washington DC. Professor Iwahara from Tokyo visited and observed some actual reconstructive surgical procedures in RPMI en route to that conference. He was astonished to observe what he did and said he had never experienced such a surgical skill in his life. Professor Iwahara assured me that, without hesitation, all medical faculty members would approve my establishment of the new Department of Plastic Surgery at Keio University Hospital. However, I extended my stay for another year in order to take the examination of the American Board of Plastic Surgery, because RPMI was only credited for 6 months residency, necessitating at least an additional 6 months residency or more somewhere else.

My request to extend my stay for another year was granted and with a recommendation by Dr Hoffmeister I moved to the Institute of Reconstructive Plastic Surgery (IRPS) at New York University Hospital as a clinical fellow. Professor John M Converse was the chair of IRPS, a top expert in craniofacial surgery in the USA. Professor Converse was in charge of the Foundation of the Craniofacial Disfigured as well, and I learned surgical techniques directly from him from July 1964 to June 1965.

After passing the American Board of Plastic Surgery examination in May of 1965, I returned home via Europe. Just before leaving New York City, my fiancée and I decided to marry and were invited by Professor Converse to his private home, a penthouse along Park Avenue where we celebrated our wedding on July 6, 1965. Professor Converse also suggested that I visit his personal friend Dr. Paul Tessier in Paris, the founder of craniofacial surgery, providing me with a personal letter of introduction to him.

When visited Dr. Tessier at Foch Hospital at Suresnes in the Paris suburbs in July 1965, Dr. Tessier kindly demonstrated for me the surgical instruments he had invented and showed me his own techniques for craniofacial surgical procedures. Dr. Tessier and his wife invited my wife and me to a lunch at Café Fouquet's on the Champs Elysees where we had a wonderful time together, and later he invited me to come and work in his Hospital. However, I could not accept his kind offer because I had been charged with establishing the new Department of Plastic Surgery at my home University. In turn, I offered this opportunity to my student Dr. Hideo Nakajima, who accepted my offer and studied under the auspices of Dr Tessier at Foch Hospital in 1979 and 1980.

We extended an invitation to Professor John M Converse and his wife to attend the eighth annual meeting the Japan Society of Plastic Surgery in Sendai in November 1965, which was presided over by Professor Naganori Kirisawa, chairman of ophthalmology, University of Tohoku, Japan. Professor Converse presented a special lecture entitled, “Some New Techniques for Reconstruction of the Ear.” After the meeting, Professor Converse visited Keio University Hospital in Tokyo and enjoyed sightseeing in Tokyo with me.

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ESTABLISHING CRANIOFACIAL SURGERY/PLASTIC SURGERY CENTER AT KEIO UNIVERSITY IN TOKYO

On my return to my home country, I had been very appreciative of all my experiences and the assistance I had received in the United States. I was able to learn plastic surgery at 3 prominent institutes, and no one in Japan at that time had more experience than me with regard to both breadth of knowledge and surgical techniques. Therefore, I became active in many plastic surgical fields and was soon elected as one of the youngest ever board members of the Japan Society of Plastic Surgery.

Because I was the only clinician in Japan who had learned the art of craniofacial surgery directly both from Professor John M Converse and Dr. Paul Tessier, it became my dream to establish the Japan Society of Craniofacial Surgery. In 1983, Professor Yuya Namba of Plastic Surgery at the University of Nagasaki organized the Japan Society of Maxillofacial Surgery, inviting me to become one of its board members. However, the Society's bylaws clearly excluded the craniofacial surgery and I chose to resign from that society.

Following that life-changing meeting at La Napoule in France in 1985, I proposed the foundation of the Japan Society of Craniofacial Surgery to Professor Yuya Namba. Though he agreed with me, he wanted to change the name of the Japan Society of Maxillofacial Surgery to the Japan Society of Craniomaxillfacial Surgery instead. Because only 2 of us. Dr. Hideo Nakajima and I had specialized in craniofacial surgery at that time, yet I was obliged to compromise and accepted his proposal. On my return home, I was nominated as one of the board members and the fifth president of the renamed society, the Japan Society of Craniomaxillofacial Surgery.

The International Confederation of Plastic, Reconstructive and Aesthetic Surgery was held in Paris in 1987. The presidential dinner was held in the Orange Room of the Palais de Versailles, where Dr. Tessier invited my wife and me to join him at his table. Not long thereafter, I was able, in turn to invite Dr. Tessier to attend the thirty-second annual meeting of the Japan Society of Plastic Surgery held at Sheraton Grande Tokyo Bay Hotels and Towers in April 1989, which I presided over as chairman. Dr. Tessier presented the keynote lecture, entitled “State of Art: Craniofacial Surgery.”

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AN EARLY CASE OF COMBINED CRANIOFACIAL SURGERY AND MICROSURGERY

Facial transplant is an emerging surgical subspecialty in which a craniofacial surgeon acts as a team leader for complex transplantation procedures. Facial transplantation requires an interdisciplinary approach, including the combined use craniofacial surgery and free microvascular composite tissue transfer. Historically, combined craniofacial and microsurgery approaches began in the 1970s, following the emergence of microvascular free flap transfer. I reported on one of the very early cases of complex facial reconstruction using this combined approach in 1975.

A clinical report: A 19-year-old male came to us with the chief complaint of facial asymmetry: his right orbit was displaced posteriorly and caudally; his right eye was enucleated previously at other hospital, right ala was smaller than the left, located more cephalad; his right commissure was higher than the left; he had hypo plastic right maxilla and had right side soft tissue defects as well. Our diagnosis was congenital facial hemi-atrophy. Our plan was to create a skeletal correction, followed by soft tissue correction with vascularized free tissue transfer. On March 25, 1974, via bicoronal incision, the right side of his facial bone (orbit, zygoma, and maxilla) was cut, en block, and advanced 1 cm forward. The resultant bony gap was filled with a rib and iliac bone graft and fixed with steel wires. In the following May, his cheek soft tissue defect was filled with free de-epithelialized deltopectoral free tissue transfer.1 Eleven years later, follow-up showed that the surgical correction was well maintained2 (Fig. 1 ).

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APPLICATION OF SURGICAL SIMULATION FOR CRANIOFACIAL SURGERY

Today, we are living in the golden era of information technology, such as AI and virtual reality. Simulation surgery has become crucial both for the education and training of young craniofacial surgeons, due to the reduced number of hands-on experiences in many craniofacial centers around the globe. In the 1970s, I started working on simulation surgery and computer-aided surgery, back when the personal computer did not even exist3: I began studying the mechanism of orbital fractures from a mechanical point of view, with analysis aided by computer. After the emergence of 3D CT technology, I and my colleague Dr. Nakajima successfully used 3D CT as an aide for surgical planning of 10 cases of total cranial vault remodeling in the years 1988 to 1990.4

A clinical report: a 1-year-old boy presented with a narrow and pointed forehead and mild clover leaf skull deformities (Fig. 7). Three-dimensional CT demonstrated skull deformities with pansynostosis, and occipital mesh-like bony defects. Surgical planning was performed using SurgiPlan. Frontal osteotomy was first made on the computer. Next, 2 bandeau, parietal bandeau and occipital bandeau were constructed on the image: these 2 bandeaus are the key structures determining the amount and degree of calvarial expansion. Next, several bone strips were connected between supraorbital bone and the parietal bandeau. The rest of the area was then constructed with multiple strips of calvarial bones. Figure 8 represents the sequence of simulated surgery on the computer.

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Figure 9 demonstrates the actual surgical sequences. Similar to simulation, several bone strips were connected between the supraorbital bone and parietal bandeau. The rest of the area was then constructed with multiple strips of calvarial bones. Bone gaps were filled with banked bones. The surgery was successful in terms of similarities between simulation and actual surgery with satisfactory outcomes (Fig. 7). Based on 10 cases of total cranial vault remodeling, my conclusion was that the cranial simulation surgery system (SurgiPlan) helped the surgeons understand the skeletal anatomy of each individual patient and assess the feasibility of the planned operation.

FIGURE 9

FIGURE 9

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SURGICAL SIMULATION AS AN EDUCATIONAL TOOL

Today, it has become very popular to create a life-size skull model preoperatively based on CT data and cut the skull model for preoperative planning and simulation surgery. The understanding of and ability to grasp the details of 3D form by 3D models are better than those from 2D CT scan film. 3D model simulation is especially helpful for inexperienced surgeons as a simulation tool or for educational purpose for medical students. We were one of the earliest groups to begin using this methodology.5 Figure 10 shows a preoperative simulation with life-size scaphocephaly model. The model was cut, and remodeling surgery was simulated.

FIGURE 10

FIGURE 10

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AFTERWORD

It is with a sense of great humility and enormous pride that I look back at my decades in the field of plastic and reconstructive and craniofacial surgery, knowing I was the driving force behind its inception in Japan. However, behind me in turn, supporting me, teaching me, and encouraging me during my formative plastic surgery years in the United States and Europe have been many of the true giants in this field, and I will always accord them my total respect and deepest gratitude. Without their knowledge and technique, which they selflessly taught me and my peers, I would certainly never have been able to accomplish so much in the field of plastic and reconstructive surgery, and in particular, craniofacial surgery. Finally, I would like to say a special thank you to my wife Ikuko, who has stood with me all along the way, and given me strength and her untiring support.

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REFERENCES

1. Fujino T, Tanino R, Sugimoto C. Microsurgical transfer of free deltopectral Derma-fat flap. Plast Recontr Surg 1975; 55:428–434.
2. Fujino T, Taino R, Sugimoto C, et al. Case Report. An eleven-year follow-up case of facial hemiatrophy treated by combined approaches of craniofacial and microvascular surgeries. Keio J Med 1985; 34:123–128.
3. Satoh TB, Fujino T, Nakajima H, et al. Theoretical analysis pf mechanism of orbital blowout fracture with digital computer. Japan J Plast Reconstr Surg 1974; 17:550–556.
4. Nakajima H, Kaneko T, Kurihara T. Toyomi Fujino, et al. Craniofacial surgical simulation system in the 3-dimensional CT SurgiPlan system. Simulation and Computer-Aided Surgery. London, UK: John Wiley & Sons Ltd; 1994. 122–135.
5. Kobayashi M, Fujino T, Nakajima H, et al. Significance of solid modelling of the skull using laser curable resin in simulation surgery. Europ J Plast Surg 1993; 16:47.
Keywords:

Combined craniofacial and microsurgery; history of craniofacial surgery in Japan; simulation surgery

© 2019 by Mutaz B. Habal, MD.