Dr Simran Deo discusses the historical rise of rhinoplasty and explains the Indian origins behind this common procedure
Rhinoplasty today is in the top 10 most common surgical procedures in the UK for men and women, with a total of 2,977 procedures performed in 2014.1 With so many of these procedures being conducted, it is interesting to note that rhinoplasty is not a new concept and has in fact been around for thousands of years.
In 800 BC the father and founder of the ancient Indian system of medicine, known as Ayurveda, unknowingly performed the first rhinoplasty.2 Sushruta, an ancient Indian physician became a well known ‘escape’ for those who had previously become victim to nose removal, a common punishment for many behaviours at that time, particularly adultery.2
Sushruta’s anatomical work
Sushruta, was especially known for Shastra karma or ‘The Art of Surgery’, one of the eight branches of Ayurveda. His texts, Sushruta Samahita or Sushruta’s Compendium on Medicine in which he describes the detailed study of anatomy, with the aid of a cadaver, is one of the main basis for modern medicine, particularly in India.3 These texts describe in detail many interesting techniques that were used in the past, including the method of preservation of the human body for anatomical study. Such preservation methods mentioned include clearing the intestines, wrapping the body in bast (the inner bark of trees), grass or hemp and left for seven days in a cage underwater before then brushing off the skin.2
This great medical man performed many surgical procedures, with cataract extraction and rhinoplasty being his fortes. He categorised surgery into eight sections:3
The rhinoplasty procedure?
In describing the method of rhinoplasty, Sushruta documented requirements that were substantially different to those we see today. He stated that the light should be suitable, with the procedure being undertaken on a bright day, and the patient should be fed and bathed prior, with particular importance paid to the area to be operated on. The patient was then positioned face down, with feet facing away from the ‘doctor’ and then tied and restrained.4
Initially the portion of the nose was measured with a leaf, and a piece of skin of the required size was then dissected from the living tissue of the cheek and retracted back to cover the nose, with a remaining pedicle still attached to the cheek. This was done in order to maintain a good blood supply to the graft, and to prevent its death. The area of the nose to which the skin was attached was made by cutting off the nasal stump. The skin was then placed onto the nose and swiftly stitched in two places, keeping the skin properly elevated by inserting two tubes of eranda (castor-oil plant) in the position of the nostrils in order to maintain an appropriate shape. The skin, now in its correct position, was then sprinkled with powder composed of liquorice, red sandalwood and barberry plant. Finally it was covered with cotton and clean sesame oil was continuously applied. After a few days, the wound healed and the connection with the cheek was then severed, leaving the patient cosmetically and functionally improved.2
The rise of Rhinoplasty
Not until the 18th Century, when British surgeons in India saw the attached flap surgery performed, did the procedure make headway into Northern Europe. This continued until a century later when grafts were used using tissue completely excised from the source.4
In India the attached flap method remained, however its method altered, leading to many variations of Sushruta’s original procedure. In around 1794 AD, two English doctors discovered these methods.4
Although the Indian method of rhinoplasty is well known and well used, its adaptations are also used. For example, Italian professor Gasparo Tagliacozzi’s method of using an upper arm flap has further been adapted by Song et al. Their deltopectoral flap is thought to be valuable in total or partial nasal reconstruction. The flap is raised from the dectopectoral region using a patch of supraclavicular skin to provide the external covering for the new nose.5
Sushruta also underwent a method of the pedicled cheek flap, where the skin of the flap is not completely excised but instead remains attached to its source location, in this case the cheek. This is in order to maintain a good blood supply to the flap or graft. This pedicled cheek flap method has been the inspiration of many great surgeons, including J.C Carpue, Branca the Elder, and the Italian surgeon Tagliacozzi.6
In 1961, Eduard Schmid used pedicled flaps from the eyebrows, with skin flaps from the temple area as grafts for nasal reconstruction. This largely depended on the hair arrangement of the patient, but was preferred by many purely due to cosmetic reasons ie. skin colouration.7
Maratha Vaidya of the Kumhar (potter) caste was an individual who had learnt Sushruta's method over time, and whose work was witnessed by two British officers, Thomas Cruso and James Findlay. This led to the spread of the method to Europe via its publication in the Madras Gazette and subsequently in the Gentleman's Magazine of London in October 1794.4
The pedicled method, now known as ‘Indian plastic surgery’ is well used due to the presence of a persistent and good blood supply. Cosmetically, it is also sound due to the similarities in colour and texture of the skin found on the cheeks and the nasal skin. The later developed forehead flap, used by Vaidya, was the first stage of evolution of Sushruta’s method, resulting in a widely used procedure, which still remains to this day.4 The pedicled area remains, maintaining a good blood supply to the grafted area, and its appearance post-operatively is just as good, if not better than that produced by the cheek flaps.
Today the Indian procedure of rhinoplasty is still frequently used and remains to be one of the few ancient ‘rituals’ still around. Although it is now not normally used to reconstruct a nose lost by punishment for adultery, it is still an operation greatly required, if not just for cosmetic reasons. Rhinoplasty these days is currently undertaken more often by those born with nasal congenital malformation such as a cleft palate with an invasion of the nasal cavity. It is also an important treatment for those who have suffered trauma to the nose or undergone removal of a tumour. Infection leading to the loss of a nose is uncommon in the young, but often found in the elderly or in third world countries such as India where rapid medical treatment is not possible due to the vast population.
As reported by journals and historians over the years, the techniques used in rhinoplasty have varied little, resulting in minimal progression of the procedure, with any new adaptations arising to refine the original method. In fact, the historical outlook on rhinoplasty permits the definite conclusion that the reported Indian methods for nasal reconstruction have prevailed, whereas the procedures used by Tagliacozzi and Graefe are hardly being applied any longer. This can be explained for nosological reasons, since during the past century the forehead and other parts of the face were often scarred, and thus unable to be used as repair tissue. The past century has also brought on the importance of beauty in society, thus leading to increased popularity in the use of Schmid’s method, due to its cosmetic advantages. Today however, microsurgery is overtaking the use of macrosurgery, and with the ability to perform vascular anastomosis, the source of grafts is limitless. The ancient Indian nose may soon be left in ancient times.
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