In Memory of Kenneth E. Salyer, MD: My Great Mentor in Craniofacial and Cleft Surgery

Akira Yamada, MD, FACS

‘‘I am never satisfied.’’

‘‘Flow state is the key to excellent surgery.’’

‘‘ I do previsualization before I begin to operate.’’

‘‘Creating balance and harmony are the keys to craniofacial surgery.’’

—Kenneth Salyer, MD

 

Kenneth E. Salyer, MD, FACS, FAAP, a founder of International Society of Craniofacial Surgery, a founder of International Craniofacial Institute Cleft Lip and Palate Treatment Center in Dallas, Texas, a founder of World Craniofacial Foundation, passes away on December 28th, 2020, due to the complication from stroke. When you look back in history, great surgeons have always been influenced, inspired, or mentored by other great surgeons. For Dr Kenneth E. Salyer, his great inspiration and the person who inspired

him and guided him to become expert in craniofacial surgery was Dr Paul Tessier of Paris.

 

Dr Kenneth E. Salyer was a pioneer of craniofacial surgery in the United States. He became the youngest chief of plastic surgery at the University of Texas Southwestern Medical School in Dallas Texas in 1969, at age 32, at a time when modern plastic surgery began to flourish. He was often frustrated, however, because he had to turn away many patients with craniofacial deformity because he felt he could not provide satisfactory results. Dr Salyer was a perfectionist, and he was still looking for a solution when he was invited to New York University in 1971 to observe Dr Paul Tessier’s 13 hours of surgery on a Crouzon disease patient. Dr Salyer was electrified by this experience and it changed his life.

 

When Dr Salyer hosted the Symposium on Plastic Surgery of the Orbital Region, held in March 1974 in Dallas, giants of plastic surgery such as Drs Tessier, Joseph Murray, John M. Converse, Milton Edgerton, Donald Wood-smith, and Mutaz Habal attended. While in Dallas, Dr Tessier scrubbed in on 6 of Dr Salyer’s

craniofacial cases at Children’s Medical Center in Dallas. Dr Salyer later wrote that ‘‘the experience was bit like taking piano lesson from Beethoven,’’ and from that moment on he devoted himself more and more to craniofacial surgery.

 

During that same symposium, Dr Salyer suggested to a group of young surgeons he met in Paris 2 years before that they form an international craniofacial club, which would allow them to rendezvous at least once a year, present to each other their most challenging cases, their newest techniques and advances, and solicit help with the problems they could not yet solve, as well as enjoy some recreational time together. This was an era that was pre-email and pre-Internet, and the group—often called by Dr Salyer the ‘‘band of brothers’’—included Drs Linton Whitaker, Fernando Ortiz Mon- asterio, Ian Munro, Ian Jackson, and Daniel Marchac. This Band of Brothers opened new territory in infant craniofacial surgery, where Dr Tessier never ventured, and together the group ultimately trained more than 250 craniofacial fellows.

 

In 1978, Dr Sam Noordhoff, the father of plastic surgery in Taiwan, invited Dr Salyer to Chang Gung Memorial Hospital in Taipei. Dr Salyer performed the first craniofacial surgery in Taiwan, including 3 hypertelorism cases and, as a result of that trip, craniofacial surgery in Taiwan was successfully launched. Two residents assisted Dr Salyer’s surgery: Drs Yu-Ray Chen and Fu-Chan Wei. Dr Chen later became the first Kenneth Salyer fellow, then emerged as a world-renowned expert in craniofacial surgery. Dr Fu-Chan Wei became an equally renowned expert in microsur-gery, and Chang Gung Hospital became perhaps the center for the education of surgeons from around the world in these disciplines.

 

After 10 years as chief of plastic surgery at the University of Texas Southwestern Medical School, Dr Salyer moved to private practice. He convinced a number of experts to join him, including Drs Derek Bruce (pediatric neurosurgeon), Ian Munro (craniofacial  surgeon), Ed Genecov (orthodontist), Ken Shapiro (pediatric neurosurgeon), and Grady Crosland (pediatric anesthesiologist) at Medical City Dallas where together they established a unique, private, multidisciplinary institute dedicated to craniofacial surgery

with great administrative support.

 

Dr Salyer recognized the importance of imaging in craniofacial surgery. He brought in Mike Lorfing from UTSW Medical School and developed a first-class imaging studio. The ‘‘International Craniofacial Institute Cleft Lip and Palate Treatment Center’’ flourished; his charisma and skill attracted patients from 75 countries around the world. Medical City Dallas allowed international  patients a 50% reduction in hospital charges—something virtually impossible to obtain now. In order to care for even more indigent children with craniofacial deformities, Dr Salyer established the  World Craniofacial Foundation in 1989. Educating the next gener- ation surgeons became Dr Salyer’s secondary passion, and the WorldCF craniofacial fellowship, begun in 2000, was one of the first ACGME-accredited craniofacial fellowships in the United

States. One of the fundamental aims of the WorldCF was to support the development of new craniofacial centers and improve existing centers help throughout the developing world.

 

I first met Dr Salyer in 1996, and he was my mentor for the past 25 years. After I completed my plastic surgery residency in 1994, I was looking for a subspecialty I could embrace for the rest of my professional life. But the only clues I could find were in books, journals, and at meetings. I was very interested in craniofacial surgery, but there was no official craniofacial training in Japan. Then, I happened to read Richard Faltin’s symposium summary in the Scandinavian Journal: ‘‘Craniomaxillofacial Reconstruction:

How to Do It’’ (1995, supplementum, Scandinavian University Press). In that journal, all-star craniofacial surgeons presented excellent outcomes of many kinds. Among them, I was especially attracted to one who talked about balance and harmony as the keys for excellence. I wanted to become his disciple, but for a new attending-surgeon at a university hospital in the countryside of Japan, there was no way I could imagine ever meeting him. Yet in 1996, I became a disciple of Dr Satoru Nagata, the preeminent microtia surgeon. It seemed like a miracle, but through his introduction, I was able to meet Luci and Ken Salyer in the Philippines at a craniofacial meeting.

 

I spent 3 years with Dr Satoru Nagata—from 1997 to 1999. During that period, I spent entire energy for ear-reconstruction surgery. Then, I began a craniofacial fellowship with Dr Salyer, and he told me, ‘‘you

are meant to be here.’’ In the operating room, Dr Salyer initially cut our first patient’s left side to demonstrate his techniques, then he let me cut the right side, carefully watching as I worked. We ultimately performed more than a hundred intracranial procedures together. These were life-changing experiences for me. Dr Salyer’s skill in cranial vault remodeling was fascinating. He was often in ‘‘flow state,’’ as he called it. Dr Salyer and I did more than 300 cleft cases together, including primary lip/nose repair, palatoplasty, secondary rhinoplasty, and over 50 cases of orthognathic surgery.

 

From 1969 until 2006, Dr Salyer operated on 5770 craniofacial patients and 5479 cleft lip and palate patients. After Dr Salyer retired from daily clinical activities in 2006, he devoted his entire energy to his World Craniofacial Foundation and improving craniofacial centers around the world. His passion for teaching, demonstrating surgery, and lecturing continued until his death. For the past 15 years, Dr Salyer and his WorldCF team, including Drs Bruce, Raul Barcelo, Diego Steinberg, Joe Michienzi, and I traveled

to perform complex intracranial craniofacial cases in countries such as Libya, Egypt, South Africa, Argentina, Mexico, China, Russia, Uganda, Oman, Laos, India, and Colombia. At the time of his death, he was planning to visit India to perform complex facial cleft surgery in the spring of 2021.

 

I learned many things from Dr Salyer during my fellowship and the 20 years that followed. Dr Salyer and the author traveled many countries together for lecturing and demonstrating surgery (Fig. 1). Here are only a few things I learned from him, and I would like to share them with you:

 

PREVISUALIZATION

 

Dr Salyer had background of artistry and possessed extraordinary three-dimensional perception. He taught me the importance of ‘‘previsualization,’’ and ‘‘lights and shadows,’’ as we analyzed and planned craniofacial surgery. Life-size photos of various angles were always hanging in the operating room to help us visualize

preoperative goals. Dr Salyer always worked to improve his own photography techniques, and he loved taking photos. After my fellowship with Dr Salyer, my photography skills had significantly improved and now continue to help my clinical work.

 

SAFE SURGERY

 

Even though he was open to new technology and new techniques, Dr Salyer’s priorities were always patient safety. He often emphasized how important it was for craniofacial surgeons to work with

excellent pediatric neurosurgeons and anesthesiologists to ensure excellent and safe results. Dr Salyer’s approach to cranial vault remolding was very dynamic, but at the same time he handled bones very carefully and cared about the brain as much as good neurosurgeons do.

 

FLOW STATE

 

What makes an experience genuinely satisfying is a state of consciousness called‘‘flow.’’ During flow, people typically experience deep enjoyment, creativity, and a total involvement with life. Dr Salyer was often in flow state for cranial vault remodeling and it was magical to witness him in those moments.

 

PREPLANNING

 

Nowadays, it is almost routine for craniofacial surgeons to use life-size skull models for preoperative planning. Dr Salyer started using this new imaging technology in the 1990s, and he worked closely with Andy Christensen, who founded Medical Modeling. He utilized more than a hundred life-size models donated by Medical Modeling in his world-renowned separation of conjoined Egyptian twins in 2003, and the models were one of the decisive factors in the triumph of the twins’ separation.

 

ENDLESS REFINEMENT

 

Dr Salyer was never satisfied with current techniques. He always wanted to do better. He was open to new ideas but was only interested in excellent outcomes. If the condition of a patient was out of his area of expertise, or if he felt surgery should be performed by another expert in order to achieve a truly excellent outcome, he was never hesitant to refer the patients to others.

 

He was a superb mentor and a great friend, and I will always miss him. Dr Salyer died on December 28, 2020 in Dallas, Texas.

 

The Journal of Craniofacial Surgery Volume 32, Number 2, March/April 2021

 

Copyright © 2021 Mutaz B. Habal, MD. (Used with permission)

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