Paul Louis Tessier
Authors: B. M Jones
Journal: BMJ (2008)

Paul Tessier was one of plastic surgery’s greatest innovators. His original description of techniques for craniofacial reconstruction had a huge impact on plastic and maxillofacial surgery, creating the new subspecialty of craniofacial surgery and giving hope to many with severe facial deformities that were previously untreatable. He had an insatiable will to progress even into his eighth and ninth decades. Never content that a patient should look “better than they did before we started,” he declared “if it is not normal, it is not enough.”

Paul was born in August 1917 at Heric, near Nantes. 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. He considered forestry but finally 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. A visit by Dr Veran, his teacher in infectious diseases, was arranged, and “in 10 seconds” he diagnosed typhoid myocarditis. Paul was especially impressed that 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—so Paul took up rowing! Its attraction was the “total effort” involved “from fingers to toes,” which reflects well his attitude to life.

Paul escaped death for a second time in 1943. He would have been the on-call surgical resident on the afternoon American B52 bombers destroyed Nantes and its hospital had not students he had successfully coached for their exams invited him to a celebratory picnic on the river. The duty resident’s room was destroyed and his deputy killed.

Paul developed an interest in the treatment of facial deformity from observing techniques of repairing cleft lip and palate as a resident. The destruction of Nantes forced him to move to Paris, where, with little money, he was obliged to accept first an administrative job (he left because he saw no patients), then one as a steelworks medical officer (he was sacked because the unions complained he was too strict in interpreting sick leave). Finally, in March 1946, he joined the paediatric service at Hopital Foch, where he was later to undertake his groundbreaking work.

After the war he began spending a month or two in England twice each year with the “big four” of plastic surgery—Gillies, McIndoe, Mowlem, and Kilner—from whom he learnt many new ideas (“it was a revelation”) and developed a fondness for this country which remained with him. Always focused on his goals of learning, Paul later “disappeared” for six weeks during a supposedly administrative Marshall plan trip to the United States so he could see the great plastic surgeons of the day at work there.

In 1957 a young man consulted Paul with a facial deformity, the like of which he had never previously encountered. He described it as “prodigious exorbitism with a monstrous aspect.” His subsequent research led him to believe that the deformities represented Crouzon disease resulting in severe maxillary hypoplasia, exposed eyes, and respiratory obstruction. Gillies had previously tried an operation to move the whole upper jaw and lower part of the orbits forward and commented to others “never to do it.” Undeterred, Paul sought to clarify the difficulties by working on dry skulls at home and then cadavers. Since he had not been to medical school in Paris the medical establishment denied him access to an anatomy room. Characteristically he did not give up but travelled regularly to Nantes at the end of his working day to do dissections there, returning on the 2.30 am train to be back at work in Paris by morning. This painstaking preparatory work typified his thoroughness and dedication. Finally, when he was ready, Paul successfully operated on his patient, completely freeing the facial skeleton from the cranium, advancing it by 25 mm, and securing it by the novel use of bone grafts.

The procedure was an enormous achievement in itself, made more remarkable since he had only simple tools (no power saws and drills) and was denied access to orthodontic splints, hitherto always used to stabilise facial fractures, because of a historic dispute between the plastic and maxillofacial services at Foch.

He had simultaneously become interested in the correction of orbital hypertelorism and had the completely revolutionary idea that if the orbits were approached from inside the skull they could be mobilised and relocated safely without damaging either the eye or the brain. This contravened all accepted neurosurgical dogma but together with a gifted, open minded neurosurgeon, Gerard Guiot, he spent three years devising a method to shift the orbits medially via a transcranial approach. In 1964 they carried out their first clinical case but it was not until he presented his work in Rome in 1967 that Paul realised the enormity of its impact. Such was the interest generated that he organised a meeting at Hopital Foch later the same year to which a number of distinguished neurosurgeons and plastic, maxillofacial, and ophthalmic surgeons were invited, together with paediatricians. Over a 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 in view of the inherent risks. They gave their enthusiastic support. Paris had become the birthplace of the new specialty of craniofacial surgery and Paul’s approach to problem solving—“pourquoi pas”—was adopted as the motto of the international society when it was formed in 1983. He was invited to be its honorary president.

Over the ensuing years Paul not only pursued and developed his ideas but trained the first generation of craniofacial surgeons worldwide. In 1972 he carried out the first craniofacial procedure in the United Kingdom at Great Ormond Street, where he continued to visit, teaching in the operating theatre and clinics, for 25 years. On one memorable occasion, into the 12th hour of a particularly difficult operation, he was informed that the hospital lecture theatre was packed with an audience waiting to hear him speak. His reply, unique but typical was, “What can I do? I have a patient, they will have to go home.” We finished the procedure at 11 pm, having started at 7.30 am—when I asked whether he would like to return to his hotel to rest the reply was “non, non, I am very ’ungry: I want to go out to dinner.” For the record, the day concluded at 3 am the next morning. At 7 am he rang me to see how the patient was—fortunately I knew him well enough to anticipate this and was at the hospital. On another occasion I presented him with a 28 year old man whom he had never operated on during a teaching symposium. Paul instantly recognised him from having met him in Paris as a 1 year old (unbeknown to me). He recalled his Figian origin, his father’s occupation, and, remarkably, had slides of him as a baby at the bottom of his bag! The audience must have thought it stage managed but it was entirely spontaneous.

Those who did not know him well may not have seen his sense of humour. He complained bitterly to me at being collected at Waterloo station and being taken via Trafalgar Square to The Wellington Hospital on one trip—“I do not take you to the Napoleon Hospital when you visit Paris!” At the height of the BSE (bovine spongiform encephalopathy) crisis he insisted on eating “crazy cow” and, on being served his beef, pressed the bemused waiter “are you sure it is crazy?”

Paul’s capacity for work was extraordinary, but he should not be thought of as a man without other interests. He had a passion for big game hunting and organised many expeditions through uncharted areas of Africa, living for many months with native trackers whose mysterious skills he greatly admired. Art, and in particular sculpture, was a major preoccupation, which he incorporated in his studies of facial form and used to benefit so many patients. As befits a Frenchman, he loved great wines, fine food, and Havana cigars.

His contribution to medicine cannot be overestimated. The ability to liberate the orbits and face from the skull not only revolutionised the treatment of severe congenital deformity but also contributed to major advances in the management of orbital and skull base tumours, facial trauma, and asymmetry. He never sought the limelight but could not avoid many prestigious international honours such as the Jacobsen innovation award of the American College of Surgeons and the Gillies lectureship and gold medal of the British Association of Plastic Surgeons. He became chevalier de legion d’honneur in 2005.

Paul was an extraordinary man driven by the true explorer’s desire to respond to a challenge, devise routes around apparently insurmountable obstacles, and so to progress. His peculiar gift of obstinate combativeness, allied with a genuine tenderness and concern for his patient embodied 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 of us who knew him, had the opportunity to absorb his principles and benefit from his teaching have been rarely privileged.

He leaves his wife, Mireille, daughter, Laurence; and son, Jean-Paul.