The History of Rhinoplasty Part II

February 21, 2020
Nasal Cartilages

Early History

It wasn’t the 1800s, the middle ages, or even Ancient Rome that we first began sculpting and reconstructing our noses.  It was 3,600 years ago during the 2nd Intermediate Period of the Ancient Egyptian Empire in 1600BC that we first read about the earliest descriptions of rhinoplasty.  We’ve learned this, in part, from Edwin Smith, an Egyptologist from Connecticut, who bought a 15-foot-long papyrus in 1862 that is filled top-to-bottom with hieroglyphics. (The Smith Papyrus now rests at 103rd and 5th in the New York Academy of Medicine). Within these lines of hieroglyphics are the clinical presentations of 48 trauma cases. It’s like an ancient board review book – a monumental medical and historical document.

Original Egyptian Papyrus

The Egyptians lay out the same diagnostic and treatment method taught in medical schools today.

They describe a problem, go over the examination, discuss the prognosis and then detail the appropriate treatment.  Unlike other medical professionals of that era (and every era including today), the authors of the papyrus (mostly) avoid the use of magic, incantations, and superstition to make a rational case for the best treatment. In many cases they detail in essence what we surgeons practice today – 3600 years later.

They write about what we now call “triage”, dividing new patients into groups based on how much or how little they can be helped.

The Egyptians use three groups: “An ailment I will treat”, “An ailment I will fight with”, and for the most unfortunate Egyptians: “An ailment for which nothing can be done”.  Here’s one of those 48 cases, translated from 3600 B.C.:

Title Practices for a wound in his nose.

Examination and Prognosis If you treat a man for a wound in his nostril, which is obstructive, and if you find the lips of that wound shifted from each other, you have to fasten the wound for him with stitches.  Then you say to him: “One who has a wound in his nose, which is obstructive: an ailment which I will treat.”

Treatment You have to make for him two swabs of cloth.  You have to wipe every eel of blood that is knotted inside his nostril.  You have to bandage him with fresh meat the first day.  If his stitches loosen after you have taken away the fresh meat from it, you have to bandage him with an oil and honey dressing every day until he gets well. How much as changed since this was written approximately 170 generations ago?  Much of the general technique is the same, but luckily the technology has improved. For example, tonight, if I’m paged to the ER - what would I do if find a nose with an open laceration? Number one - suture it up to align the edges (fasten the wound with stitches).  Number two - ask the patient to keep the wound clean from clots and scabs (wipe every eel of blood). Number three – keep the inflammation down with ice, Tylenol, keep the nose elevated (or, before ice and Tylenol: bandage with fresh meat – salt fights the swelling).  Lastly – have the patient use antiseptics like hydrogen peroxide or an antibiotic to prevent infection (bandage him with an oil and honey dressing).  

Let’s do another, more challenging, example:

Title Practices for a fracture in the chamber of the nose.

Examination and Prognosis If you treat a man for a fracture in the chamber of his nose and you find his nose crooked and his face flattened, while the swelling that is on it is high, then you say about him: “One who has a fracture in the chamber of his nose: an ailment I will treat.”

Treatment Set it back in its proper place. Wipe for him inside of his nostrils with two strip(s) of cloth until every eel of blood that is knotted inside his nostrils comes out.  Afterward, you have to push two plugs of cloth wet with oil into his nostrils.  You have to set for him two stiff rolls of cloth bandaged on it and treat (him) with an oil and honey dressing every day until he gets well.

I could cut and paste this for next week’s teaching rounds. When I meet a patient that’s taken a soccer ball (or a right cross) to the nose I’d reset it in much the same way.   (With one merciful addition – I’d numb the nose with lidocaine beforehand). For a nasal fracture I’d put a flat, spatulated instrument in the nostril and push and pull the paired nasal bones back to the middle with a little crack.  It’s timeless because it works.  We’d also insert some gentle packing in the nose so the bones stay in the middle – not too dissimilar to the “two plugs of cloth wet with oil”.  Also the Egyptian “oil and honey dressing” doubles for salads.

These examples illustrate how the ancient Egyptians laid out an organized, stepwise approach to nasal surgery. They examine the patient, settle on a diagnosis and treat.  Sounds like an obvious progression. So obvious, you may wonder why after building on this foundation in 1600 BC we haven’t been able to come further than we have in the 21st century.   For example, the Papyrus describes sliding salted bacon slices into the nose to stop a nosebleed.  Sounds ridiculous, but we’ve learned that salted bacon really works for nosebleeds.  Strange, but true. In fact emergency rooms kept salted bacon on hand for this purpose well into the 20th century.  If the Egyptians had discovered a useful detail this specific 3,600 years ago, why isn’t modern medical management even further along?  

As we’ll read, progress with rhinoplasty – and medical progress in general – rises and falls with the peaks and valleys of human civilization.

You may assume, as I did, that doctors living in 1500BC would have fewer tools than those in 1000BC.  And those in 1000BC would have fewer tools than 750BC.  This is not the case!  The Edwin Papyrus was one of a few high water marks for the millennia that followed. Egyptians of the era enjoyed the safety, prosperity, and population density necessary to make these medical discoveries. If you lived elsewhere, or after these civilizations collapsed – you may have been out of luck if you broke your nose.  There is no steady ascent over time. Medical progress is more like the stock market with dips and jumps (but over time a good bet things should improve).

Elsewhere in the world, around the same time as the Edwin Papyrus, another high water mark was cresting in nasal surgery. Ancient India, 1500BC - the four main books of the ancient scriptures of Hinduism known as the Vedas were being compiled. These early Sanskrit texts, which up until this point had been passed orally from generation to generation, contain the roots of the founding of the Ayurvedic tradition.  Until this writing I was not familiar with the Ayurvedic practices. Today, however, Ayurvedic practitioners are seeing patients all over the world. It’s seen as a pseudoscientific companion to modern medicine.  While its modern practitioners are not performing rhinoplasties, ancient Ayurvedic texts describe some of the earliest techniques in nasal surgery.  

Fast-forward about 1,000 years to a slightly less Ancient India.  Here we’re introduced to the famous surgeon Sushruta Samhita of Banaras University, the first surgeon celebrity.  In approximately 600BC, Sushruta Samhita (by himself or with some help) built on Ayurvedic practices to write Sushruta’s Compendium – consisting of 6 books and more than a hundred chapters on medicine and surgery. Writing in Sanskrit, the author(s) put a sharp focus on rebuilding the nose.  

Why? Because, as we’ll learn, medical discoveries are a reflection of what’s ailing the population.  If a certain population eats a diet that causes gallstones you’re more likely to find innovations in gallbladder surgery.  Or if the average citizen doesn’t beyond 45 years the doctors are unlikely to make strides in Alzheimer’s research. What was one ailment encountered during Sushruta’s time? Rhinectomy - slicing off one’s nose as a form of punishment.  Thieves, adulterers, and others condemned during the era were relieved of their noses with a longsword. So the Compendium includes instructions on how to rebuild a nose – which, unbeknownst to Sushruta, would be essential reading for more than a millennium as the corporal punishment continued across civilizations.

For example, to briefly skip ahead in time, Byzantine emperors that were deposed would undergo rhinectomies in the process.  This wasn’t just to rub the nose of the outgoing ruler in a military defeat but also to ensure that they wouldn’t try and retake the throne. Justinian II, emperor from 685 to 695 C.E. suffered this fate.  He was dethroned and had his nose and tongue sliced off in front of 1,000s of cheering former subjects in the Hippodrome. (But he fought his fate and staged a successful coup 10 years later.) These rhinectomies pop up again more than a 1,000 years later in 1770 when King Narayan in India conquered a town and ordered the removal of all the noses of all the male populants.  He later renamed the city Naskatapoor – “the city without noses”.    

Thus Sushruta and his colleagues were challenged to find novel methods to remake a nose from scratch. A challenging task, considering the state of medical knowledge in 600BC. They didn’t understand that the heart circulated blood.  They did not understand the purpose of the brain. This was thousands of years before the germ theory and skin histology and the mechanics of healing. But the Compendium still describes techniques we use today, 2,600 years later.

Here’s how they described repairing a nose in 600BC:  

History of Rhinoplasty

First, the leaf of a creeper (plant), long and broad enough to fully cover the whole of the severed or clipped off part (of the nose), should be gathered, and a patch of living flesh, equal in dimensions to the preceding leaf should be sliced off…from the region of the cheek and, after scarifying it with a knife, swiftly adhered to the severed nose. Then the cool headed physician should steadily tie it up with a bandage decent to look at and perfectly suited to the end for which it has been employed.  

Much of this still holds true.  We don’t use the leaf of a “creeper”, but we do measure the size of the missing skin on the nose with a sterile bandage.  Then we move that measuring tool to the skin around it, and measure how much healthy surrounding skin we need to rotate atop the missing region to reconstruct the defect.

Sushruta’s instructions for after-care:

…the adhesioned part should be dusted with powders of Pattanga [red sandal], Yashtimadhukam [licorice root], and Rasanjana [antimony] pulverized together, and the nose should be enveloped in Karpasa cotton and several times sprinkled over with the refined oil of pure sesamum...  

Admittedly I haven’t yet researched the beneficial effects of red sandal, licorice root or antimony, but we’re still applying ingredients like extracts of the flowering plant Arnica montana, onion elements like Mederma®, and pineapple plant extracts like bromelaine onto wounds with some success.

One final excerpt: The adhesioned nose should try to be elongated (beyond) where it would fall short of its natural and previous length, or it should be surgically restored to its natural size in the case of the abnormal growth of its newly formed flesh. The physician who is well conversant with these matters can alone be entrusted with the medical treatment of a King.

This, as Sushruta neatly summarizes, is the real art of rhinoplasty.  The nose should “try to be elongated (beyond) where it would fall short of its natural and previous length”. A nose’s appearance on the surgical table does not neatly translate to that nose’s appearance a year later. The experienced rhinoplasty surgeon has to sculpt a nose that settles right where the nose’s owner wants it.

The Sushruta Compendium was one of the principle early texts codifying Ayurvedic Medicine. While the modern Ayurvedic practictioner does not perform surgeries like rhinoplasty as written in the Compendium, the ancient practices have remained consistent.  According to Ayurveda, we should strive to achieve a delicate balance between mind, body, and spirit for overall wellness. The three elemental substances of health (“humours”, “doshas”) are “wind”, “bile”, and “phlegm”.  (You may have friends and relatives that come to mind for each one).  According to theory if our wellness is ignored and one dosha outpaces another, predictable unwanted effects and pathology will result. Lastly, the way in which they subdivide the medical specialties contrasts sharply with Western medicine.  A Sanskrit text in the 4th Century BC described the eight components of Ayurvedic medicine as: General Medicine, Pediatric Medicine, Surgical Techniques & the Extraction of Foreign Objects, ENT, Pacification of Spirits & Treatment of Minds Possessed By Those Spirits, Toxicology, Rejuvenation and Promotion of Lifespan, and finally, Techniques for Increasing the Viability of Semen and Sexual Pleasure (“Aphrodisia”).  Living in New York you can make a diagnosis in each category just riding the subway.

public domain

Just as we’ve seen with the Ancient Egyptians and Indians rhinoplasty advancements mirror the progress of human civilization.

Advancements in our understanding of the human body and surgical arts are made by pioneers living and working within civilizations that can provide general safety and well-being to its citizens while rewarding fresh thinking and avoiding religious suppression of scientific study. The further leaps of human innovation continue on in Ancient Greece, the Roman Empire, the Renaissance, the European Industrial Revolution and beyond.

And so we’ll jump ahead to ancient Greece and the “Father of Medicine”, Hippocrates – born in 460BC and dying around 370BC.  Hippocrates is credited with defining medicine as a distinct field, apart from philosophy, theology, or others.  He helped lay the ground rules for the modern physician – record the knowledge you gain in text so that they may be passed on and built upon, treat based on empirical evidence rather than superstition, and form organized training programs for new physicians.  He placed the focus on epistemology, continually asking “how do we know this to be true?” These ideas and more were codified in the text The Hippocratic Corpus. Here, the authors introduce new practices and theories that have stood the test of time. They write that all maladies have an organic cause, including epilepsy, which was previously known as the “sacred” disease because of its possibly spiritual or divine etiology.  They also set forth an ethical code: the Hippocratic Oath – including “First, do no harm”.  Medical students still pledge this oath during “white coat ceremonies” during their first year.

Similar to Ayurvedic medicine, Hippocrates and his acolytes believed in humors.

Each one was associated with a certain mood or disposition.  They were also more or less conspicuous in certain seasons and times of life and were also associated with specific bodily organs.  If you had too much of one or too little of another it led to predictable ailments or personality deficiencies.  “Blood”, “Yellow Bile”, “Black Bile”, and “Phlegm” – you can read the associated temperament of each and diagnose your friends. The Hippocratic practice of “humorism” was at the core of educated medical practice until the 1800s despite having no foundation in actual anatomy and physiology.  At least it was an attempt on empiricism – which by itself is a significant leap forward. Much different than the mystical and superstitious religious medicine seen across the centuries – obviously before, and unfortunately after, too.

Hippocrates’ impact on rhinoplasty technique is found through texts written by Aulus Cornelius Celsus 300 to 400 years after Hippocrates’ death in 25BC, during the time of emperor Tiberius.  Aulus served as a creator of encyclopedias, and he wrote a seven-book text on everything from Military Arts to Philosophy to Jurisprudence.  His book, “De Medicina” (On Medicine) took much from the Hippocratic Corpus and detailed the diagnosis and treatment of nasal surgery that progressed the field forward.  

Celsus describes the Hippocratic method of fixing broken noses: For bony lesions, put the bones back in place with your finger, then cover the nose with cerate (wax mixed with oil, lard, and some medicinal ingredients) to set it. It requires pressure because can form a bony tumor if not rigidly set…  If infection occurred after a laceration through the nose, De Medicina directs the physician to debride the wound by removing cartilage then applying lyceum (a flowering plant) dissolved in water then covered in lint.

The four temperaments

Other suggestions in the text tell us that we’ve made some progress over the last 2,000 years.  Celsus required those patients being treated to fast during periods of inflammation following injuries.  Hippocrates writes – if you eat while ill you’re feeding the illness.

Following the collapse of the Greek and Roman empires, the Dark ages came and went with very few advancements in rhinoplasty or surgical techniques in the Western world.  Pope Innocent III and the Council of Tours proclaimed that surgery was interfering with God’s plan and was to be abandoned by the schools of medicine and all “decent” physicians. Also the social status of the surgeon had changed -  performing manual operations like surgeries were seen as below the dignity of an educated doctor. However, surgical techniques were kept alive largely in secret by passing on the principles from one generation to the next within medical families – and thankfully the surgical texts from Ancient Egypt, India, Greece and Rome were maintained.

One exception that survives from the Dark Ages is from Bald’s Leechbook, published in 920AD in modern day England.  It was written in Olde English and gives some insight as to the status of medical and surgical practice at the time. The Leechbook compiled Mediterranean medical practices and homespun charms, folklore, mysticism for the treatment of both internal and external maladies.  Bloodletting was still very much en vogue - used to equalize the body’s humors. The book described removing warts by applying mouse blood and dog urine.  It treated baldness by spreading willow leaves and burned bees mixed with oils across the scalp – presumably because the leaves and bumblebees are themselves covered in a fine fur. Not forgetting the nose, if a patient was suffering a persistent nosebleed the physician was instructed to stick an entire husk of barley in their ear so the patient will become unaware of the nosebleed. During the Dark Ages in the Western world the clergy were the main sources of learning and treatment - rather than independent, evidence-driven anatomists and physiologists. This stalled progress rather than building on the progress made in rhinoplasty and medicine by ancient civilizations. One notable counterexample - there was a recent discovery that the use of a certain anti-infectious agent made partially from cow-bile described in Bald’s Leechbook may help treat hospital-acquired MRSA infections.  

Not everyone was shoving barley into earholes during the Middle Ages, though.  The Ancient Indian texts from Sushruta Samhita that had snaked its way through the centuries were translated by Ibn-Abi Ubaibia into Arabic in 13th century Damascus.  He published it as part of an extensive history of famous physicians from prior civilizations in 1245AD.  From this book it was later passed to Egypt, then finally to the West in the 15th century in a text entitled Cerrahiyet-ul Haniye (“Imperial Surgery”).

The Foundation of the Modern Era

This brings us to 15th century Italy, where the seedlings were laid for the modern techniques we practice today.  It’s during the Italian Renaissance that after centuries of stagnant thought and coating bald heads with bee secretions we have a rebirth of scientific, artistic, and political thought and progress.  New industries and trade resulted in before unseen wealth.  Decreased institutional religious hindrances allowed for surgical research and exploration. It was a good time to be a rhinoplasty surgeon.  Just ask the Brancas from Sicily and the Vianeos from Calabria.

In Italy at the time, dueling with rapiers was the Renaissance version of arm wrestling.  As you’d imagine, many an Italian nose was lopped off during these duels – which sent surgeons scrambling for a passable reconstructive technique. Enter the Brancas and Vianeos.  Likely benefitting from the surgical texts originating from Indian and transcribed in the Middle East these Italian families described the biceps transposition flap for nasal reconstruction.  With this procedure, the surgeons would draw the outline of the nose to be reconstructed on the skin atop the biceps muscle.  They’d cut out the outline of the nose with a scalpel, leaving it attached (and the blood flow intact) at its north end.  Then they’d bring the arm up to the face, and sew that flap of skin to the region that had been previously sliced off, thus reconstructing the nose.  A harness of sorts was fashioned for the patient to keep the arm in close proximity to the head for a few weeks.  During these weeks following the first procedure, the skin from the arm that was “transposed” to the face gains a new blood supply from the facial skin and no longer requires the blood supply from the arm.  Once this happens, the Italian surgeon can cut the connection between the arm and face and finish sew up both sites.  Thus the Italian method of nasal reconstruction was born.

Rhinoplasty, like other surgical techniques, was more akin to artisanal skills like pottery or cobbling.

These proprietary techniques were passed down from family to family, cementing their societal status. Why publicize your technique if another family down the street with a decent knife set can cut in on your business?  Its difficult to “stand on the shoulders of giants”, as Isaac Newton wrote, when the most modern and advanced surgical techniques were purposely performed behind closed doors.  It contrasts sharply with the “publish or perish” mantra of surgeon-scientists today.  To be fair, the Brancas, Gustavo and his son Antonio, would doubtfully describe themselves as “scientists”.  The requisite broad medical training, and research backgrounds of today’s surgeons are much different than the narrowed artisanal background during the Renaissance and centuries following. To become a leader in a surgical field today, one must not only perform the advanced techniques, but also work to improve these techniques or invent novel techniques.  Importantly - then let everyone know about it.  “You’ve been doing it this way, but this way is better – I thought of it myself ; )”.

More than a century later, however, another Italian surgeon named Gaspare Tagliocozzi turns this model on its head with the publication of e Curtorum Chirurgia per Insitionem (“On the Surgery of Mutiliation by Grafting”) in 1597.  Tagliocozzi refines the techniques described earlier by other European surgeons and codifies them in his surgical atlas.  He’s able to make such strides by dedicating hours and hours dissecting executed prisoners at the “Hospital of Death” in Bologna.  He was dedicated to the details, tireless, and willing to share his discoveries – all essential traits that caused a frameshift in the evolution of surgical practice.

Tagliocozzi writes, “We restore, rebuild, and make whole those parts which nature hath given but which fortune hath taken away. Not so much that it may delight the eye but that it may buoy the spirit, and help the mind of the afflicted”.  With the successful publication of his atlas and his reframing of the goals of surgery, Tagliocozzi helps to take the surgical practice from an “empirical state of development” to a “work of art”.  Today, many consider him the founder of Plastic Surgery.

But, as mentioned, medical progress is not a continuous ascent from Gaspare Tagliocozzi to today.

Progress in any form – human rights, religious freedom, music that kids listen to – is often more like a pendulum than a staircase, and rhinoplasty is no exception.

The art of nasal surgery declines over the next two centuries. This happens for a few reasons, and each point to a worthy lesson.

First, the surgeries described during the Italian Renaissance weren’t perfect, and instead of improving upon them most surgeons ignored them completely.  For example, some would perform the biceps transposition procedure by using a slave’s arm to reconstruct his or her master’s nose.  Ethically, medically, morally – this was a poor development. One story goes that this procedure was performed and the master subsequently moved away, parting ways with the slave that had provided a segment of his arm for his master’s nose.  According to the story the skin survived, however, until one year later when the master’s reconstructed nose suddenly blackened and fell off.  The master soon learned that his slave had died at that very time.  Those who heard this story concluded that the life force of the body part still depends on the initial owner.  You can imagine these techniques, and their inherent complications, didn’t increase the Italian method’s popularity.

Second, the church butted back into the scientific conversation.  Again, the clerics restricted reconstructive surgeries and research as altering God’s work.

Gaspare Tagliocozzi

Third, the techniques in Tagliocozzi’s atlas were hard to do.  Some surgeons, sensing the precision that the modern rhinoplasty techniques would require, advocated instead that the patient use a prosthesis made from wood, paste or silver. Because these techniques were tricky, other surgeons recommended unwise alternative approaches – which may have spread confusion to the scientific process. For example, Leonardo Fioravanti from Bologna published a story in which he watched two Spanish soldiers dueling.  One soldier sheared off nose of the other and the nose fell into the sand.  Fioravanti saw this and picked up the nose.  Seeing that it was full of sand, he urinated on it, and sewed it on “very firmly”.  After an 8-day hospitalization Fioravanti swears the nose was “attached once again”.  Still, you can imagine the success rates were quite low with this technique…not exactly standing on the shoulders of giants.  

Thankfully for our patients, the biceps flap and urinating on detached noses did not survive to modernity.  Today, a great many patients throughout the world have their noses reconstructed via the paramedian forehead flap.  A common scenario for the use of this “flap” includes a patient suffering from a superficial cancer on the skin of the nose. A cancer surgeon will remove the affected skin (and sometimes the deeper tissues), leaving an area uncovered on the nose that needs a new covering.  

The paramedian forehead flap was likely first performed in 16th century India.  Amazingly, we’re still performing a similar procedure five centuries later in the East and West– with great results. How did this great technique make it from India to the West? And why did Western surgeons continue to perform the morbid Italian method all the way past the turn of the 20th century?  To the latter question – the better technique took a while to get here.

The technique was first described in a letter from a Venetian adventurer who was writing home after a visit to the Mughal Empire in the late 1600s.  But this letter was quarantined for some reason in a library in Venice until 1907 and the secret procedure stayed secret.  Then in 1794, a letter was addressed to the editor of an English Gentlemen’s Magazine and published sort of as a Ripley’s Believe-it-or-Not type piece.  The piece tells the story of Cowasjee, a bullock driver for the English Army in India.  Cowasjee was captured by a guy named Tippoo, who sliced off his nose and hand.  Cowasjee survived, though, and went back to work with the East-India Company.  Twelve months later, an Indian surgeon reconstructed his nose with the forehead flap, which was witness in amazement by an English surgeon.  The letter to the Gentlemen’s Magazine began, “A friend of mine has transmitted to me, from the East Indies, the following very curious and, in Europe, I believe unknown chirurgical operation, which has long been practiced in India with success; namely, affixing a new nose on a man’s face (…)”

The author, signed B.L., described the procedure nearly identical to that which we still perform today.The defect in the nose is carefully marked out and a wax template is made of the missing area.The template of the defect is flipped 180 degrees and placed on the forehead upside down.Then the forehead skin is cut carefully around the template to match the amount of skin needed to reconstruct the nose.The skin is then left attached via a thin slip between the eyes, so that the blood flow all the way to the tip is kept intact.The bridge of skin is then flipped 180 degrees to cover the nose and is fixed atop the defect to cover it completely.Luckily there’s enough laxity with the forehead skin that the edges can be brought together with some tension. Twenty-five days later, the bit of skin that came from the forehead but now sits atop the nose is fed well enough from the blood supply of the nose and the bridge that connects the nose and forehead can be safely separated.

Now with the word out in the West, the technique sparked a rebirth in nasal plastic surgery.

The first Western surgeon to popularize the technique was Joseph Constantin Carpue, and English rhinoplasty surgeon at St. Bartholomew’s Hospital in London.  In 1814 Carpue met an English officer whose nose was amputated during a battle in Spain.  Carpue had read about the “Indian method” and tried to give it a try.  The reconstruction lasted all of 35 minutes – with no anesthesia.  The officer later said, “It was no child’s play –extremely painful- but it was no use complaining”.  Once it was done, the officer looked in a mirror for the first time and exclaimed, “my God, there is a nose!”  Carpue published his experiences with the Indian method two years later with the apt title, Account of Two Successful Operations for Restoring a Lost Nose From That of the Forehead.  The rhinoplasty community loved it.  In true Western fashion, the procedure later became known as “Carpue’s Method”.