The History of Rhinoplasty Part III

February 21, 2020
Nose base view

The Modern Era of Rhinoplasty

As a facial plastic surgeon, we’re not expected to learn much in the way of history during our decade of post-collegiate training. We’re taught the latest and greatest techniques, and maybe one or two techniques that were tried in the past and abandoned.  But without a historical perspective, how can a budding rhinoplasty surgeon understand how much (and how little) we’ve accomplished and how much further we need to go? Essential reading for my trainees is to learn of the “Great Century of Berlin Medicine”, starting with Karl Ferdinand von Grafe (1787-1840).  

Born right before the signing of the U.S. Constitution, von Grafe trained in Germany and became a professor of ophthalmology.  Then later, during the Napoleonic wars, he left his academic post to take over the military hospitals.  There, he saw his share of poor souls in need of facial reconstruction.  And Dr. von Grafe was forced to improvise, adapt, and improve on existing methods to help the maimed and mutilated.  Towards the end of his career, he summarized much of his techniques in a seminal text called, “Rhinoplastik” – “the art of organically replacing a missing nose”.  He describes the Indian method of reconstruction, the Italian method, and his own modifications and advancements.  Over the course of his career von Grafe kept innovating. He was the first to use the term “plastic” regarding plastic surgery. He was coined the term “blepharoplasty” in 1818.  He invented many cleft palate repair techniques, lip reconstructions, and “V-Y” advancement flaps.  He was a pioneer, and the rhinoplasty community took notice.   “Rhinoplastik” lit a fire in Western Europe regarding the practice and refinement of plastic surgery techniques. And he passed his pioneering genes onto his son, who later became a famous ophthalmologist.  Then the good stock skipped a generation when von Grafe’s grandson became a famous anti-Semitic politician competing with Hitler for the rule of the far right in the 1920s.

The next German rhinoplasty Hall-of-Famer was seven years younger than von Grafe. Johann Friedrich Dieffenbach (1794-1847) was mentored by von Grafe and succeeded him as professor at the Charite (“Charity”) Hospital in Berlin in 1840. At Charite Hospital Dieffenbach, like von Grafe, was faced with battle weary soldiers and all sorts of incomplete faces. He applied the forehead flap technique for never before tried practices. He used the skin of the forehead to reconstruct the inner lining of the nose.  He put together defective noses of unheard of severity.  He also treated patients with paralysis of the face, and was one of the first surgeons to sever the healthy nerve from the opposite side to achieve balance.  He corrected problems that few contemporaries thought had a surgical solution, like strabismus and torticollis.  He was among the first surgeons to anesthetize his patients prior to rhinoplasty He even got a little over caffeinated (apparently) and tried to fix a stuttering child by incising the root of the tongue.

Word of his abilities spread and his fame achieved rockstar proportions. He joined the entourage of Friedrich Wilhelm IV, King of Prussia. Foreign guests from around the world traveled to his Berlin clinic.  A plant was named in his honor – the Dieffenbachia. The public loved him, he became the celebrated subject of a popular children’s song. He died in his early 50s of a cerebral aneurysm – ironically while he was in the midst of explaining an aneurysm case to two visiting French physicians.  But not before he was able to publish his expansive surgical atlas, Die Operative Chirurgie, in 1845.

Johann Friedrich Dieffenbach (1794-1847)

With all these new sophisticated techniques, their applications begin to cover more and more ground as we move to the late 1800s. Previously “rhinoplastik” was a means to reconstruct those following rhinotomy as punishment, or following a duel, or on the battlefield.   But this would soon change.

Rhinoplasty, and plastic surgery as a whole, would begin to see patients interested not only in reconstruction, or return to their baseline appearance, but seeking a new appearance altogether.

As the risks decrease and the techniques improve aesthetic surgery grows in popularity.  Otherwise healthy patients wanted new noses.  

This introduces the concept of “physiognomy” – the use of facial features as a determinant of character.  Patients then, as now, sought cosmetic changes they thought would be beneficial to their self-worth.  But the specific changes they ask for varies widely from one generation to the next.  For example, gently removing a dorsal “hump” on the nose is a common surgical request.  However in the not-so-distant past the “aquiline” nose – with a “hooked” appearance from the side – represented nobility and a superior intellect. You’ve heard of the prominent “Roman nose” - taken from the large and projected noses of the busts of the ancient Roman emperors.  It represented leadership and strength.  

But jump nearly two millennia to the 1800s and the “hawk” nose signifies a “cheating moral character”.  The cute, small, upturned nose and narrow tip come into vogue – and can still be seen on dozens of older ladies living in the Upper East side.

Nowadays, a less “done” and more natural outcome are most desirable.

People are rarely hoping for narrow tips, and sloped nasal bridges – they also often want to keep the family traits that make their nose their own.  These trends over time show that there is no perfect shape.  What’s popular today is just that, “popular”.  It may change from one era to the next, or one decade to the next.  It depends on new fashion trends, the celebrities of each generation, demographic changes, immigration, and more.  It also shows that the “science” of physiognomy is not science. Some of this comes from benign sources – like ascribing qualities of leadership and intelligence to the facial features of the heroes of the era.  But it also comes from darker places. Believing that certain facial features imply dishonesty or selfishness has racist and anti-Semitic undertones. The nose itself, before or after rhinoplasty, has no bearing on the quality of the person that owns it.

While the “science” of physiognomy rose and fell the era of German dominance in rhinoplasty continued. Jacques Joseph (1865 – 1934) was not a likable man.  If you visited his clinic, he’d allow you no questions, no comments, and would make you pay to watch.  He downplayed the achievements of other rhinoplasty surgeons and took criticism very badly. But watching him work was likely well worth the money – Joseph was arguably the most important rhinoplasty surgeon in history.

He was born 18 years after Dieffenbach’s death - the third child to a rabbi in Konigsberg, Prussia.  During his first surgical position he was fired for performing a maverick unsanctioned ear correction on a 10 year-old boy.  (He performed it correctly). He then founded a private practice and started a new era in facial plastic surgery.  Jacques Joseph believed that a person whose appearance caused a social or economic disadvantage is afflicted just like anyone suffering from a debilitating disease.  Wanting a normal, or “ideal” appearance was not vanity – it was “anti-dysplasia”.  This new era coincided with the elevation of surgery from charlatanism to highly respected and intensely rigorous training programs that landed surgeons in the upper echelons of society.  

Dr. Joseph moved through the ranks with a chip on his shoulder - some would say for good reason.  After he was fired from his first position, he distinguished himself as a war surgeon during WWI.  He came to the attention of Kaiser Wilhelm II, the last emperor of Germany (and oldest grandchild of Queen Victoria).  The Kaiser offered Joseph the position as Chairman of Plastic Surgery at Charite Hospital – but only on the condition that he converted from Judaism to Christianity.  Joseph declined.

But he charged ahead. In 1919 he became a professor in the Department of Facial Plastic Surgery at the Ear, Nose and Throat Clinic.  Here and later after forming his own clinic he invented dozens of technical innovations.  He was the first to use composite grafts in which you transfer a layered piece of cartilage and skin from one area to another, hugely important in rhinoplasty.  He pioneered the endonasal approach by which all incisions are hidden inside the nose.  Dr. Joseph also designed his own surgical instruments, which we still use today.

Jacques Joseph (1865 – 1934)

From 1928 to 1931 Joseph published his findings in three seminal texts from a pioneering career.  He gave it the snappy title Nasal Plastic Surgery and Other Facial Reconstructive Procedures, With an Appendix on Reconstructive Breast Surgery and Some Other Procedures in the Area of External Plastic Surgery.  He revealed a softer side by dedicating the book to his wife and even using her picture as an example of the perfect nose.  The publication cemented his status as a once-in-a-generation surgeon, the public called him Dr. “Noseph”.  Surgeons who studied under Jacques would go on to their own great heights in rhinoplasty.  Surgeons like Dr. Gustave Aufricht later founded the Plastic & Reconstructive Surgery Journal as a staff surgeon at Lennox Hill Hospital in New York. Dr. John Marquis Converse became the surgeon-director of the Manhatten Eye, Ear and Throat Hospital (MEETH) and founded the Department of Plastic Surgery at NYU.  Dr. Samuel Fomon learned from Jacques Joseph during the many anatomic and surgical courses and later passed along these pearls to Dr. Maurice Cottle of Chicago, and Dr. Irving Goldman of New York.  Rhinoplasty surgeons undoubtedly recognize each of these names – all legends.  Each contributed to their corner of the rhinoplasty world, as well as design the very instruments we use in surgery.  During each procedure you’ll hear a rhinoplasty surgeon asking for a “Joseph elevator”, “Cottle elevator”, “Converse retractor”, “Goldman bar”, and “Aufricht retractor”. All acolytes of Jacques Joseph and giants in their own right.

An American contemporary of Joseph, John Orlando Roe, was an otolaryngologist that similarly produced dozens of rhinoplastic innovations.  Dr. Roe was a Long Island native.  He studied first at the University of Michigan and later the Columbia College of Physicians and Surgeons before traveling to the epicenters of surgical innovation at the time in Vienna, Berlin and London to fine-tune his training.  He settled in Rochester, NY to start his practice.  

It was here in upstate New York that he developed clever innovation after innovation like Edison in his laboratory.  He invented the endonasal technique by hiding all the surgical incisions inside the nose.  He started blowing iodoform antiseptic powder on the wounds to prevent infection after learning of Louis Pasteur’s discoveries.  He was the first to use cocaine, not in a Studio 54 type way but as a topical and injectable anesthetic.  He invented the standardization of “before” and “after” rhinoplasty photos. He was also a powerhouse administratively, leading the New York Medical Society and American Laryngological Association and others.  All of these still exist today.  

While Jacques Joseph may not have liked the competition, this generation of rhinoplasty surgeons ushered in a new era in the 20th century, an era of science defined by the free exchange of ideas. Centuries earlier territorial surgeons would protect their technical secrets to maintain their commercial edge.  Thanks to the new rhinoplasty leaders of the time surgeons were now publishing their advancements and allowing other surgeons to visit their operating rooms and witness their techniques. The entire surgical community benefited, and the innovators became etched their name in the rhinoplasty history books.

It was not long ago that facial plastic surgeons were reconstructing noses with cheek flaps and arms flaps after war injuries or capital punishment.  Then the standards of living increased along with the efficacy of anesthetics and consistency in technique.  Patients became willing, and more able to afford, purely aesthetic changes to their noses.  And the surgeon’s mindset changed with the times.  Joseph and Roe and Dauffenbach were willing to operate even just to make the nose more proportional, to add to the patient’s sense of self-worth.  Facial Plastic Surgery became a specialty all its own, with its own journals, illustrated textbooks, surgical courses and now widespread open-door policies, where colleagues trade ideas and collaborate.

Thanks to these surgeons setting the stage, other equally creative and pioneering rhinoplasty surgeons continue to tick off essential advancements in the field.  

1899 – Dr. Friedrich von Mangoldt first uses rib cartilage to repair a “saddle” nose.

1914 – Dr. F Koenig first reported using a composite graft of cartilage and skin transplanted from the ear to the nose.

1921 – Dr. Aurel Rethi of Budapest describes the first “open approach” - accessing the nose with rhinoplasty through a small incision in the columella, the skin between nostrils.  This remains a primary approach used today.

1953 – Dr. Irving Goldman of New York City publishes the nasal tip shrinking procedure he later performs on thousands of women from the Upper East Side, known affectionately as “The Goldman Tip”.

1956 – Dr. A Sercer from Zagreb describes making changes to the bridge of the nose through the “open approach”, making the now commonly used approach widespread.

1965 – Dr. Jack Anderson from New Orleans describes cartilage splitting incisions from inside the nose as well as being the first to call the projection of the tip from the face a “tripod”, with one leg standing erect between the nostrils and the two outer legs flaring toward the eyes.  

1975 – Dr. Jack Sheen from Los Angeles first publishes his famous paper describing placing small grafts of cartilage on the tip of the nose to create sophisticated changes.

The advances continue to roll out every day with thousands of surgeons performing and improving upon the techniques described earlier. Patients continue to see better and better results.  And the ideal result continues to change from one generation to the next, sometimes one celebrity to the next. It remains the most complicated facial plastic surgery performed today.  Days-long conferences are held multiple times per year just discussing, arguing and awing over new techniques, trends, and results.

But the single most important rhinoplasty advancement in history has been the better ability to make advancements.

Rhinoplasty surgeons now excitedly exchange tricks of the trade so that one great idea begets another. And international facial plastic surgery academies have formalized surgeons’ training. It’s now more competitive than ever to become a rhinoplasty surgeon, and the surgeons these formal programs produce are much more consistently skilled and reliable than ever before.    

So it’s a great time to be a surgeon and be a patient. Which is good, because from all the way back to ancient Egypt to today, people have always and will always want to change the shape of their nose. Surgeons have always and will always oblige.  And just as with anytime a physician lays hands on a patient, the procedure must match the exact need of the patient.  In rhinoplasty this may be difficulty breathing, recovering from an accident, or hoping to sculpt their nose into the shape they’ve always preferred.

The surgery must match the capabilities of the surgeon and the times, whether they have antiseptics, anesthesia, or the gall to flip their forehead down to reconstruct the nose.  The second will always scramble to catch up with the first, and surgeons and scientists are working together to keep us on point.  Stay tuned to see what happens next.