Annals of the Royal College of Surgeons of England (1991) vol. 73, 346-347
Dr Paul Tessier
According to Evelyn Waugh it is only when one has lost all curiosity about the future that one has reached the age to write an autobiography. Perhaps this is why Paul Tessier has said he will never write one. His original description and subsequent development of techniques for craniofacial reconstruction have changed the face of plastic and maxillofacial surgery, creating a new subspecialty and giving hope to many with severe facial deformities which were previously untreatable. But what makes him truly exceptional is his insatiable will to progress, to improve his results, so that now, in his eighth decade, when most would be content to rest on past achievements, he is still producing new ideas. He is not content that a patient should look ‘better than they did before we started’, rather his philosophy is that ‘if it is not normal, it is not enough’.
Paul Louis Tessier was born in August 1917 at Heric, on the Atlantic coast of France, near Nantes. There was no family background in medicine. His parents were wine merchants, but his great grandfather was a blacksmith, and perhaps it was here that the seeds of a skill for moulding hard tissues were sown. His initial ambition was to join the Navy as an engineer, but this was thwarted by a combination of illness and injury which caused loss of time from college so that his maths was not strong enough. His thoughts then turned to forestry, but he finally decided on a career in medicine and entered Nantes medical school in October 1936. In 1940 he became a prisoner-of-war. Fortunately he was held near Nantes for he became desperately ill with neither the French nor German doctors able to make a diagnosis. Since he was thought to be dying, a visit by his mother was arranged. She in turn persuaded the French captain to permit Dr Veran, Tessier’s teacher in infectious diseases to see him. A diagnosis of typhoid myocarditis was made ‘in 10 seconds’, but Tessier was much impressed that with a series of questions and answers Veran made his captors believe that the idea had been theirs! Release followed in 1941, because of the illness, with a warning to take life easily. He did not much care for this advice and developed a passion for rowing which continued for 40 years. Its attraction was the ‘total effort’ involved ‘from fingers to toes’ which says much about the man.
Fortune was again to smile on Tessier in September 1943. By now back at Nantes as a surgical resident, he and a colleague spent a year coaching five students for their exams. When four of them gained the top four places a celebration was planned. Tessier swapped duties with a friend and the party rowed to a restaurant. They were subsequently woken from a post-prandial snooze on the riverbank by the sound of American B19 bombers and by the time they had rowed back, the centre of the city had suffered great damage. The hospital had been hit, and in particular the duty resident’s room was destroyed with Tessier’s friend killed.
After its destruction it became impossible to pursue a career in Nantes so Tessier left for Paris. He gained acceptance as a visitor in the maxillofacial service at the Red Cross Hospital with Virenque, but, since he had little money, was forced to accept a job in administration reviewing disability pensions of employees injured during the 1914-1918 war. There was no opportunity to see patients here and soon he left to become the medical officer in a steelworks. This appointment was shortlived because he was dismissed after complaints from the unions that he was too strict in applying the rules for sick leave! He then moved on to a plywood factory (‘it smelt good’). An interest in plastic surgery had been kindled in 1942 while working as a resident with Robert Bureau, a general surgeon who carried out some surgery for cleft lip and Dupuytren’s contracture, and finally Tessier joined the paediatric surgery service at St Joseph in November 1944. The chief was Georges Huc who, although basically a paediatric orthopaedist, was a friend of Veau and treated cleft lip and palate and hands. He was to have a great influence on Tessier who regarded him as a calm, good surgeon, a true gentleman and father figure.
After the liberation of Paris, the Red Cross Unit was transferred to Hôpital de Puteaux then to Hôpital Foch in March 1946. Tessier went with Virenque, where they were joined by a second maxillofacial team led by Ginestet, a professional soldier, from Lyon. The two chiefs became arch enemies and ran their services completely independently. At about the same time Tessier began spending a month or two in England twice each year with Gillies, McIndoe, Mowlem and Kilner where he learned many new ideas (‘it was a revelation’) and developed a fondness for this country which has remained with him. The ‘Marshall plan’ gave an opportunity to visit the USA. However, the party with which he travelled was full of bureaucrats whose methods did not accord with Tessier’s more direct approach. Consequently, after a dull week in Washington he ‘disappeared’. There followed 6 weeks in New York, a month in San Francisco, Los Angeles and St Louis returning again to New York, during which time he saw many of the leading American plastic surgeons of the day including Aufricht, Converse, Connley, Bunnell, Boyes, Brown, Byars and others.
In 1949 the Hospital Foch was taken over by the SNCF and its new director asked Tessier to stay to treat burns and carry out facial surgery. By this time, Virenque had died, so all Ginestet’s anger turned on Tessier and the Dental department was proscribed from carrying out any work for him. His interest was becoming increasingly concentrated on the face, and while the lack of any orthodontic or prosthodontic support might appear a great disadvantage to the development of such work, it is not in Tessier’s nature to be defeated. Rather, it encouraged him to overcome a reliance on retaining splints by devising a series of ingenious ‘self-locking’ osteotomies. This increasing experience in Paris was by now being augmented by an involvement in orbital surgery in Nantes and Lille at the request of two eminent ophthalmologists, Sourdille and Francois.
In 1957 a young man consulted Tessier with a facial deformity, the like of which he had never previously encountered. He was described as having ‘prodigious exorbitism with a monstrous aspect’. When Tessier saw him again 2 months later, having carried out some research, he knew that the deformities were the result of Crouzon disease and was of the view that the maxillary, orbital and facial deformities should be corrected in one operation. Sir Harold Gilles had published a report in 1950 of a high facial osteotomy at the Le Fort III level, but the patient’s deformity relapsed. Gillies was unhappy with the procedure, and commented to others ‘never do it’. Tessier read the article and asked Sir Harold’s artist for the original drawings of the operation to study. Convinced that the technical difficulties inherent in such surgery needed further clarification he began working on dry skulls at home, but it soon became clear that it was necessary to practise the operation on cadavers before pursuing it clinically. Here ‘the system’ again was unhelpful. Since Tessier had not trained in Paris he was granted no University facilities there and so did not have access to a dissecting or post-mortem room. Undaunted, he contacted the anatomy technician in Nantes and made arrangements to go there at night. After a working day he would board the evening train from Paris, with his theatre nurse, carry out the dissections in Nantes, catch the return train at 2.30 am and be back by morning. This was a remarkable commitment, but it should also be remembered that the only instruments available to perform the complex bony dissections were a mallet and chisel, no power saws or disimpaction forceps! Finally the patient was operated on, the facial skeleton being completely freed from the cranium and advanced by 25 mm via multiple facial incisions. Bone grafts supported the advanced skeleton, but despite all the planning the bony defects were much larger and more irregular than had been predicted. As a consequence fixation became a major problem and after 2 weeks the patient’s face remained loose. Finally an effective external fixator was constructed (not at the first attempt) and a stable result achieved.
Tessier did not see a similar case for 3 years, but he had simultaneously become interested in the correction of oribital hypertelorism. A gifted neurosurgeon at H6pital Foch, Guiot, had a wide experience of treating orbital meningiomas with immediate reconstructions often being carried out by Tessier. Here, his combined experience of facial, orbital and neurosurgery reached its apogee in devising a method to shift the orbits medially via a transcranial approach. Guiot was initially very concerned about infection from the frontal sinus and it was decided to obliterate this and reinforce the frontal dura with a dermis graft. Having done this, Tessier was not confident that he had a sufficient understanding of the deformity to mobilise the orbits safely and so there was a delay of 3 years, until 1964, before he and Guiot carried out their first complete reconstruction.
The field of craniomaxillofacial surgery had been born after a long gestation period, but it was not until he presented his work to the International Congress of Plastic Surgery in Rome in 1967 that Tessier realised that it really was something new. Such was the interest generated that he organised a meeting at H6pital Foch later the same year to which he invited a number of distinguished plastic surgeons, maxillofacial surgeons, neurosurgeons, ophthalmologists and paediatricians. Over a period of 1 week he presented all the patients on whom he had operated and carried out four further procedures, two hypertelorism corrections and two facial corrections for Crouzon disease, for their critical review. At the meeting’s end he provoked a discussion to see whether the assembled clinicians felt it reasonable to continue the surgery or not in view of the inherent risks. Fortunately they gave their support.
Over the ensuing years Tessier not only pursued and developed his ideas, but trained the first generation of craniomaxillofacial surgeons worldwide. His later contributions and refinements (which continue) are well documented and have had a profound effect on the practice of plastic, maxillofacial and neurosurgery in general, as well as producing a new subspecialty, which he would prefer to call ‘orthomorphic surgery’. His capacity for work was, and is, even in retirement, extraordinary indeed, but he should not be thought of as a man without other interests. He has a passion for big game hunting and has organised many expeditions through uncharted areas of the Republique Centrafricaine and the Sudan border along the ‘slave track’ used by Commandant Marchand in his 3-year expedition from the Atlantic ocean to the Nile river. In this pursuit he has lived for many months with African trackers whose mysterious skills he greatly admires. It is particularly the solitude and opportunity to be at one with nature which attracts him, best expressed by the French word discret. Art, and in particular sculpture, is as might be expected a major preoccupation, which he has incorporated in his studies of facial form and used to benefit so many patients.
Paul Tessier is an extraordinary man. He is driven by the true explorer’s desire to respond to a challenge, devise routes around apparently insurmountable obstacles and so to progress. This he has certainly done in making an outstanding contribution to surgery. His peculiar gift of obstinate combativeness, allied with a genuine tenderness and concern for his patient embodies a dying tradition in medicine. In an age when we are increasingly constrained by bureaucracy and the urge to publish, often without allowing due time for proper evaluation, those who have known him and benefited from his teaching have, indeed, been rarely privileged.
The Craniofacial Centre
The Hospital for Sick Children
Great Ormond Street