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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.31 no.6 Madrid nov./dic. 2009




The real origin of transfacial methodology

El posible verdadero origen de la metodología transfacial


F. Hernández Altemir1, S. Hernández Montero1, S. Hernández Montero2, E. Hernández Montero3, F. Clau Terré4, M. Moros Peña4

1 Universidad de Zaragoza (Facultad de Ciencias de la Salud y del Deporte: Licenciatura de Odontología de Huesca. España
2 Universidad Alfonso X El Sabio de Madrid: Licenciatura de Odontología.
3 Hospital de Viladecams e Instituto de Otoneurología Dr, García Ibáñez.
4 Hospital Universitario Vall d´Hebron de Barcelona. España
5 Clínica Quirón de Aragón.





Despite technological advances in a globalized world conflicts always arise about authorship of scientific procedures. To help resolve the conflicts that arise about the origin of transfacial surgery we have been entertained with bibliographical support to organize the aspects of a possible origin and author as it is understood today. Without forgetting people in history that in the XIX century foreshadowed and provided ideas from which we could determine who was the first to write the content and true possibilities. Putting those who incorporated the procedure late, with pretensions of protagonism in their place.

Key words: Transfacial access; Cavum; Clivis; Skull base.


Siempre surgen, pese a los adelantos informáticos de un mundo cada vez más globalizado, conflictos sobre la autoría de procedimientos científicos y para ayudar a aclarar los que ocurren en el origen de la cirugía transfacial, es por lo que nos hemos entretenido siempre con apoyo bibliográfico, de poner orden, en los aspectos no sólo del posible verdadero origen y la autoría de esta tal como se entiende hoy día, sin olvidar a personalidades históricas que en el siglo XIX vislumbraron y cómo no, aportaron ideas de lo que podría venir y sobre todo, quien dejo escrito por primera vez el contenido y las verdaderas posibilidades de la misma, así como poner en su sitio a los que se incorporaron al procedimiento muy tarde con pretensiones de protagonismo.

Palabras clave: Acceso transfacial; Cavum; Clivus; Base cráneo intra y extracraneal.



After the XIX European Association of Cranial Maxilla Facial Surgery Congress, September 9th-12th 2008 in Bologna Italy. It woke us up to the idea of development, the same thing that made Rainer B. Drommer, coinciding with Transfacial Access to the retro maxillary Area in J. Max Fac Surg 12 (1986), with ¨The history of the Le Fort I Osteotomy¨ a review of the most aseptic about the true start of Transfacial access as a route, not only to the rynofaringeas (where it appears to have been retained from 1981 to 1984 (Curioni C)8-10 but rather since its start in 1982 (Hernandez Altemir F) it was considered a way to comply to the pterigomaxilla, sinus esfendoidal and cranium base structures as well as the adjacent structures like the clivus.

Even although we already had advanced with other goals, we used bibliographical references about the topic, with the inestimable collaboration of the Hemeroteca of the Facultad de Medicine in Zaragoza, a major reserve and now we can say that we think we have sufficient but not excessive documentation. It doesn't seem that we need more for our proposal to praise our pretense of trying to contribute time and written content to the topic.

This does not mean that the creation and development of a new surgical technique exclusively consists of establishing its indicators. Designing the external or internal approach to get to the surgical zone of interest, resolving this and finishing the reconstruction and returning the tissues and organs involved to their place in the least traumatic way possible. Also, giving the procedure content, which is not always easy if we have only thought about resolving concrete pathologies at the present time instead of looking further ahead than that. This is what we are going to talk about.


Materials and Methods

The title that we started to work with was "History of transfacial access". When we were involved in its development we realized while making concrete dates for the numerous modifications and names that there are in the scientific market for each one of them about transfacial surgery that the topic was already about the computer and we are not IT workers. Although from that, we realized that for those that are knowledgeable about this they can develop the story of Transfacial Access with electronic support. That way they won't stop having difficulties especially because of the similarity between modifications. Where perhaps only the name of the author is for us, which could really differentiate between what is described.

We think that, in the end, experts in the history of specialized medicine will be the ones that get close to resolving our problems. We encourage it. It is definitely worth it and they should do it soon because if a lot of time goes by it could become a legend especially if the pioneers disappear and they can't defend their rights.

So, we have the material that we were able to compile with the bias of only looking for references from the most well known authors about the particular and leaving out the ones that had their own biography as pioneers of the transfacial topic.

Right away we realized that finding start dates about this was not even close to being the most difficult task, the problem was differentiated one technique from another in the various ways of approaching the fields that transfacial surgery allows. Especially to see who had been the first to give content from those who thought about the possibilities that it allowed "incindir" the soft parts of the face in the most indelible way possible so that later it could be opened like a book because maxilla fragments had osteomized and were suspended from the soft jugular tissues. In order to do this in the least traumatic way and move towards previously unknown territories. Transfacial surgery was also a stepping stone in facial procedures, endoscopic transfacial access within minimally invasive surgery.

That is how things start to clear up our understanding and it seems unquestionable that all can be summed up in schemes and published texts at the bottom of the figures that appear in Hernandez Altemir F., in ESTOMA (Medical Estomatology and Profilaxis) Volume III 1983. Number 1 pages 75-82. In the article, "Pedicle temporal dearticulation of the superior maxilla cheeks as a transfacial approach to the fundamentally retro maxilla regions and for other indicators (Maxilla perigoidea) A new technique" concentrating on Figure 1 and its foot note on page 78 where perhaps the reader can make out and eradicate the start of the transfacial access and prior, only in text also the same author,14 ESTOMA Volume II 1982 Number 1 of the article "A case of gigantic child angiofibroma of the intervened cavum using the pedicle temporal dearticulation of the upper maxilla cheek" Later we will come back to this.

During all of our bibliographical exploration, which was pretty exhausting for us, we have not found references that will go further than exploring the cavum and/or the rynopharinge moving a LeFort II type bone block, attached to the cheek, one of them appearing at the Congress level (regarding, without a doubt the earliest of our investigations) and it appears as communication in The Second Italian Congress of Maxilla Facial Surgery, Bologna November 5, 6, 7 1981 8C. Curoni, E.Padula, P.Toscazo, A. Maraggia, of the Maxilla facial Surgery Division-Presidio Ospedaliero- U.S.L. n. 8 - Vincenza Primario: Professor C. Curioni, titled "IL LEMBO MAXILLO-GENIENO: CONSIDERAZIoNI SU UNA NUOVA METODICA DE SMONTAGGIO E RIMONTAGGIO DELL INFRASTRTTURA (P.:375-377) where in the following section and schemes the viability of the suspended fragment is well specified that reminds us of a Lefort II: textually" 5) osteotomia del mascellare superiore tipo Le Fort II monolaterale interrotta a livello del tuber da una osteotomia berticale verso il basso6 osteotomia del palato mediante pinza ossivora rispettando la mucosa del pavimento nasale" in a hemilateral design of soft parts, Fergussen type and in the same way at the intra oral level, with an incision route from the palatine fibromucosa that repects the anterior nasal palatine packet and at the same time sacrifices the posterior palatine of the fragmented side when suspending and sectioning the apparently anatomically and functionally traumatic in an anteroposterior direction of the continuity of the soft paladar over passing the uvula.

The Curioni C. procedure that we just described, we couldn't read, in its brief description how the IL LEMBO MAXILLO GENIENO, it also helps us to more certainly remove angiofibromas and explore the rynopharinge or the cavum, other transcendental possibilities that since the start of 1982 we already published to get access to the base of the cranium, as we will see.

This communication and its possibilities have caught our attention, in the hands of the authors, they haven't gotten farther than exploring maxilla nasal structures and the rynopharinge, above all they weren't retaken and divulged in the medical literature until 3 years later, by the same authors as the ones we mentioned before:9 "GII ANGIOFIBROMI DEL RINOFARINGE" Considerazioni su una nuova metodica di smontaggio e rimontaggio Della inframesostruttura" Divisione di Chirurgia Maxillo-Facciale, en CHIR TESTA E COLLO 1-1984 (pages 47-569) and not even the same authors the communication10 "The Maxilla-cheek flap: A method of dismantling and reassembling the infra-mesostructure" presented in the 7th European Association for Cranio-Maxillofacial Surgery Congress, in Paris 1984, not in the biography or in the text of (9) or (10) it is not reflected in the Communication of Curioni C. and collaborators in 1981.

We are surprised that in 1984, more than three years after its use for surgeries at the base of the cranium and adjacent structures, there is no bibliographical reference to the technique: IL LEMBO MAXILLO-GENIANO: CONSIDERAZIONI SU UNA NUOVA METODICA DI SMONTAGGIO A RIMONTALLIO DELLÏNFRASTRUTTURA (Curioni C. y Col. 1981).

On the contrary, F. Hernandez Altemir, in Figure 1 expresses the possibilities of its access and also the footnote of Figure 9 on page 79, where in Volume III of ESTOMA they describe the "Temporal dearticulation." technique15 in more detail than in the description of the ESTOMA clinical case in 1982. Although in that one it already says something about the retropterigoideo and clivus space. You can also read below figure 9:The era of "open door to the back" lets us clearly see a scheme: with which without sacrificing structures we can get to the pterigomaxilla regions, rynopharinges, sphenoidal, cavum, structures at the base of the cranium, clivus, etc. which were inaccessible until now.

The following contributions have been eye-opening for transfacial surgery12 Aldo Bruno Gianni,3 Federico Biglioli, Bruno Brevi, Roberto Brusati in Journal of Cranio Maxilla-Facial Surgery (1993) 23, 325-331 and5 Andrew E Brown and John D Langdon en Ann R Coll Surg Engl with "Management of oral cancer" 1995; 77: 404-408 and the conclusions of27 Arnold Komisar, MD, DDS de New York, NY, how it develops on page 208 of ARCH OTOLARYNGOL HEAD NECK SURG (VOL. 122, FEB 1996) In the "Letters to the Editor" section, there is a letter titled "Prior Authorship" that makes reference to letters that were reinvicted by the copyright of transfacial Access that tried to allocate between26 Ivo P. Janecka, MD. Pittsburgh, Pa y7 Pete J. Catalano, MD, Hugo F, Biller, MD. New York, NY respectively and that appear on page 676, also from ARCH OTOLARYNGOL HEAD NECK SURG (VOL 120, JUNE 1994), the comments and bibliographical citations of F. Hernández Altemir in14 Estoma 1982: 3:75 and again15 Estoma Volume III Number 1 (1983) and16 Rev Ibero Cirug Oral Maxilofac 1983:5, 81, with the title of both in Spanish "Pedicle temporal dearticulation of the cheek from the upper maxilla as a transfacial approach to the fundamental retro maxilla regions and other indications" Although here there is an error by Arnold Komisar and the quote of the cavum that was operated on using the pedicled of the upper maxilla cheek technique" pages 41 and 58 of said publication. All in order to leave things in their place although we must say that in this letter we miss27 Arnold Komisar, the technicians reference to our publication and of its methodological start more developed in Estoma 1983, Volume III Num I pages 75-82 titled "Pedicle temporal dislocation to finish "Prior Authorship" the author quotes "Transfacial Access to the maxillary area" in the Journal of Maxillofacial surgery 1986;14:165-170 F. Hernandez Altemir, as an internationally relevant reference.

It seems that more authors confirm the possible copyright of Transfacial Access among others that include: (Alvarez Vincent1 Paparell Michell M,30 Sailer Hermann,31 Salyer Kenneth E,32 Suarez Nieto C,33 Talmi Yoav P.34 Vaughan E.D.35,36 Some talk about a simultaneous start Brown AMS4 between mainly C. Curioni and cols. and F. Hernandez Altemir, in a space that is for those that don't know our primitive work from 197313 to 1986.19 It should at least be reduced to chronological differences between8 Curioni 1981 and14 Hernandez Altemir 1982. Without going into detail where perhaps the second places more emphasis on the possible transfacial Access. National and international bibliography exist regarding this topic. To start to clear things up and put things in their place, always supported by contrasting facts this is with bibliographical references. Reading Works by C. Curioni and cols and Hernandez Altemir in the start of both!

In our careful revision we insist on objective information that the reader and different authors that in the future could investigate Transfacial Access, are the ones that clarify who the author is with free and true discriminatory capacity. With the support of the bibliographical references that we provide and from what we consider and insist to be important, which is the content of the two initial Works by Curioni C and cols.8 and F. Hernandez Altemir13 where the reflection of this pedicle methodology14 is reflected and later25 with what seems to manage to clearly individualize in form and content between them and the existent date in the current ample bibliographical world about this material.

We don't dare to undervalue the authors, some of which we are going to bibliographically reference, maybe not exhaustively, that have made contributions to Transfacial Access. To find a specific terminology but without detailing the modifications, that in many cases have gotten nominal denominations, everything understandable and very valuable that don't talk over a truly original score and established, movements over a structure that was born modestly consolidated and that doesn't stop being our way of seeing others have gone to the limits. We hope like in 1982, that by writing this it will give those who adventure into this topic some knowledge.

All of this because it seems that to personalities are without a doubt very relevant to the world of Oral and Maxillofacial Surgery, Otorrynolaringolgy, Neuro Surgery, Craniofacial Surgery, Base of the skull surgery, Plastic and reparative surgery head and neck surgery. They don't mention that spring was born in modern transfacial surgery. Don't forget that with great imagination and value they outlined surgical projects that fix them although they are also missing not only means but also knowledge to carry out their wishful surgeries. During that time if not the true transfacial possibilities of those designs that in some way seem o repeat in 1981 and that already were over dimensioned by Hernandez Altemir13,14 in 1973 and 1982.

We thought that we were talking about the middle of the XIX century with Langenbeck, B (1859), D.W. Cheever. (1869), T. Kocher (1897), according to an article by B. Dromer Rainer.11

That being said, to start wrapping things up we want to say that Transfacial Surgery was born and is shown in our work not as a technique but as a methodology. We affirm that we already re-taught in 1982 and 1983 how we went noting from higher up and that the specific authors that were going to confront distinct surgical pathologies in this area would have to fix them to make transfacial modifications with individualized designs for each specific case.

We don't think that this is grounds for each modification meaning a new technique with its corresponding personal nomination. Rather for us it means that we want to take it without any type of merit or professional support what they are doing in this surgery gets better day after day and that it is very possibly one of the greatest achievements in Medicine and Surgery at the end of the 20th Century.

We are not going to refer to the number of technical modifications in transfacial surgery that are in the literature and whoever wants to consider them specific techniques has the right to do so if the editorials keep letting them do it in the bibliographical citations (Masik Tarik,28,29 MELLO.FIHLO Francisco Verssimo de and col Wei William37 and the ones cited above.



We have tried to objectively retrieve what is written about transfacial origins and its conceptual start in our modification of the radical dissection of the neck, just as we imagined it (Hernández Altemir F. in 1973, 1982, 1983, 1984 etc.) without giving any doubtful personal details or bibliographically speaking non demonstrable.

We encourage readers and those who work in transfacial surgery to contribute details that have escaped us that can be known in new publications or in letters to the president. If we have left something out we assure you that it is probably because we didn't know about it.

If we assume that, all of the work will never be complete. We don't think that "Works finished by no one "exist in any worldly aspect. But it is easier in today's world to make a truer recompilation.

We encourage medical historians or future studies to investigate about the individual, understanding that the base of transfacial surgery might have originated in13 F. Hernandez Altemir, R. Castillo Escandon (1973): "Modification of the Radical neck dissection technique" Special Sunday Edition. March 25 1973 Vol. I Number 5, (pages 3-10). This is where we pedicle about the blocked surgical removal of the tissues that are removed during a simple radical neck dissection. In this procedure the maxilla mandible structures and hang from the cervical flap (F. Hernandez Altemir and col.25 "Preserving the Organ" P.342, S252, Journal of Crania- Maxillofacial Surgery 36(2008) Supp.1 Abstracts, EACMFS XIX Congress) from which we later apply the Lefort II pediculation of the cheeks. If the procedure were uni or bi lateral which we later named22 Pedicled Crania-facial, which can be done with endotrachial intubation via the sub mental" (Bala Indu, Biglioli F., F. Hernandez Altemir, 1984, 1986, 1995, 2004.

With transfacial Access we were creating an opening through the facial regions that could have been damaged, in order to allow Access to the structures, which before now were unable to treat or control. With unthinkable mutilations that didn't allow the patients or the surgeons to perform the procedure in a great number of cases because of moral or ethical reasons. (Hernández Altemir F. 1994).

It wasn't Transfacial Surgery, one or another incision that determined a flap that swings over the bone fragment. In one way or another it was and is a methodology that allows us to accommodate its versatility to each individual case. This could provide us structures and organs whose damage is unthinkable. For today's society where it is difficult to except psychosomatic disharmonies because they aren't traumatic enough in our definition of damage.

This article will not be well understood if it is not easy for the reader to Access the complete published Works by ESTOMA from 1982 and 1983. These Works were cited above as well as the one by F. Hernandez Altemir "Pedicle temporal disarticulation of the superior maxilla cheeks as a transfacial approach to the fundamentally retro maxilla regions and for other indicators (Maxilla perigoidea) A new technique" Rev. Iberamerican Oral and Maxillofacial Surgery, 5, 13 (81-102), 1983 and we provide its original format so that the editors copy it integrated in the same number where "The real origin of transfacial methodology", from the Spanish Journal of Maxillofacial and Oral Surgery because its historic value is indisputable and because the originals by Curioni in 1981 and the two that were recognized in 1984.

All of this was not just to adjust the speed but rather what is most important is the contents that we have said show that Salomon gave a son to his mother because he knew what he was doing.

Historians, students, authors and readers can decide who the author of Transfacial Access and methodology is.



Dr. Don Francisco Hernández Altemir
Fray Luis Amigó, 8, planta 0, letra B
50006 Zaragoza, España
E-mail: drherná

Recibido: 28.10.2008
Aceptado: 30.11.2009




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