|Year : 2020 | Volume
| Issue : 1 | Page : 154-158
Chronicles of rhinoplasty
Harsh Suri, Gangadhara Somayaji
Department of Otorhinolaryngology, Yenepoya Medical College and Hospital, Mangalore, Karnataka, India
|Date of Submission||08-May-2020|
|Date of Decision||31-May-2020|
|Date of Acceptance||01-Jun-2020|
|Date of Web Publication||20-Jun-2020|
Dr. Harsh Suri
Flat No 103, Ocean Heights Apartments, Opposite Juma Masjid, Kuthar, Mangalore - 575 017, Karnataka
Source of Support: None, Conflict of Interest: None
The surgical reconstruction of nose also termed 'Rhinoplasty' is as old as human civilisation. While major contribution of total nasal reconstruction originated in India by Sushrutha in around 600 B.C and later paved its way to the modern facial plastic surgery in North America and Europe in 18th century and popularised the Indian methods of nasal reconstruction to develop cosmetic and corrective rhinoplasty. This article aims to take you through the journey of evolution of rhinoplasty.
Keywords: Facial plastics, nasal reconstruction, Rhinoplasty
|How to cite this article:|
Suri H, Somayaji G. Chronicles of rhinoplasty. Arch Med Health Sci 2020;8:154-8
| Introduction|| |
Otorhinolaryngology has a very rich history with important collaborators and scientists in the history of medicine. Otolaryngology was separated from surgery and internal diseases during the second half of the 19th century, after which otology and laryngology were popularized and studied separately.
Rhinology is one of the youngest fields of medicine and has been popularized as a subspecialty of ENT with nose and paranasal sinuses. This surgical specialty gained immense popularity in the 20th century due to the introduction and practice of endoscopic sinus surgery and rhinoplasty.
Today, rhinoplasty is widely practiced by ENT surgeons all around the globe, thus venturing into a new subspecialty popularized as facial plastic surgery, although the history of rhinoplasty is fascinating and dates back to about 3000 years ago.
In this article, an attempt has been made to travel through the evolution and progress of rhinoplasty.
| Earlier Times|| |
The history of rhinoplasty dates back to many centuries ago, wherein the historical era, a popular practice of punishment given to several criminal or sexual offenders, was amputation of nose (rhinectomy) or ears. Sometimes, these barbaric rhinectomies were done in a fit of rage or jealousy, even to those women who practiced witchcrafts. Although the first documented description of mutilation of the nose was recorded in the famous Hindu Mythology Ramayana where Prince Lakshmana, brother of Lord Rama, did a deliberate amputation of Lady Surpunakha's nose in 1500 BC by Nichter et al. Her brother, the Mighty King Ravana, relented this action and summoned his physicians to reconstruct her nose, which led to the first documented literature of nasal reconstructive surgery in India. This method has been described as the Indian method of rhinoplasty in the books of plastic surgery. Hence, it is believed that the origin of plastic surgery happened in India in the 6th century and later in Egypt about 3000 years ago.
Menace of the epidemic conditions such as leprosy, small pox, and lupus, especially syphilis reached its peak during the 17th century which led to severe nasal disfigurement having the classical “Saddle nose deformity” which led them to be a social outcast in the society in many parts of the world including India. To get back to their society and to be reacceptable into their social system, Martin's Tripod nasal splint [Figure 1] was used to build up the nasal bridge.
|Figure 1: Martin's tripod nasal splint for intranasal support in cases of saddle nose|
Click here to view
The first real detailed description in the world medical literature dates back to the 600 BC, in the document “Sushruta Samhita” [Figure 2] describes the nasal reconstructive technique, which he used based on the cheek flap. This is the first documented description of the use of pedicled flaps.
One of the initial documented descriptions of treatment for injured nose has been estimated to have been written about 3000 years ago by an Egyptian physician, Smith papyrus. Various aspects of the facial beauty and its description of exact facial measurements were studied and described by the famous Italian polymath – Leonardo da Vinci  [Figure 3] and [Figure 4].
Inspired by the work of Sushrutha, Branca brothers in 15th century, described their work related to total nasal reconstruction. Antonia Branca from Sicily, greatly influenced by his father's work, developed a new surgical technique by taking a flap of tissue from the patient's arm and popularized this in the entire family of reconstructive surgeons.
Gaspare Tagliacozzi of Bologna (1545–1599) hailing from the same family, mastered this skill, and popularized this procedure, which was later known as the Italian method [Figure 5]. He was not very well appreciated and was heavily disregarded and was blamed and heavily criticized for allegedly interfering with God's handiwork soon after his death. However, the Bologna magistrates honored him with a statue, which represented him as holding a nose in his hands. Much later in 1612, Paolo Zacchias, physician to Pope Innocent X th had a relook into Tagliacozzi's principles. It was believed that the tissue removed from the individual could be transplanted into the recipient while the donor continues to live. It was also a tradition back then that the grafts were borrowed from the servants, which prompted the famous satirical line: “So learned Tagliacozzius from the browny part of portresses bum etc.” This principle was extensively used during the times of World War I where extensive tissue damage was seen, leading to rise in reconstructive procedures. Tagliacozzius's work was extensively appreciated and was published 2 years after his death.
Meanwhile, a German physician, Pfalzpoint attempted using alloplastic materials and heterogenic free grafts but in vain., Tycho Brahe, a famous astronomer who lost his nose in the battle of Due, led him to wear a golden nose that gained him immense popularity and slowly developed an art of nasal reconstruction in the state. Jacques Lisfranc was a French surgeon who worked extensively in Napolean army in the 1800s popularized his technique of using a forearm flap for nasal reconstruction using cardboard for measurements for a new nose. He also mastered the forehead flap and incorporated its nourishing vessels for survival. He also described the importance of retaining the nutritional pedicle for at least 1 week so that it can survive. In 1834, August Labat of Paris, demonstrated the actual technique of folding a forehead flap to reconstruct the lower part of the nose.
Karl Ferdinand von Graefe (1787–1840) was the foremost German surgeon in the 19th century [Figure 6]. He was known for his extensive work during the times of war with Napoleon where he performs ≥50 rhinectomies a day. Devastated by this barbaric procedure, he devoted his entire time to study and develop the techniques of plastic surgery. He further incorporated Indian and Tagliacozzi's method of nasal reconstruction in Germany, in 1817.
About two hundred years ago, Von Graefe's publication called “Rhinoplastik” and its Latin version “Rhinoplastice,” which by definition means reconstruction as a creative tissue manipulation, threw a new light on the techniques of the procedure. He introduced the word “plastic” into the naming of reconstructive procedures and eventually led Edward Zeiss to name this specialty as “Plastic Surgery” in his Handbuch der Plastischen Chirurgie.
Johann Friedrich Dieffenbach (1792–1847) has been hugely credited for his various contributions to plastic and reconstructive surgery. He developed a technique of reconstruction of the mutilated noses from the remnants by putting the pieces together. He was also the first to postulate that a plastic surgeon should think and be creative like a sculptor. With his immense contribution, he went on to earn the title of “Father of Plastic Surgery.”
An American Physician, George Howard Monks (1853–1933) is credited for the description of many deformities such as saddle noses, crooked or bent noses, flat noses, and rhinophyma and also operated through a small incision between the glabella and the root of the nose. Jacques Joseph (1885–1934), a renowned German plastic surgeon, refined his methods to suit all types of deformity and devised special instruments for the purpose [Figure 7]. However, Dr. Weir from New York is credited with first Reduction rhinoplasty in 1892.
|Figure 7: Joseph's instruments were purchased by the archivist of the British Association of Plastic Surgeons. From the Antony Wallace Archive by Courtesy of the British Association of Plastic Reconstructive and Esthetic Surgeons|
Click here to view
Earlier, ether was used as an anesthetic agent until, Kapp in 1884 introduced the use of cocaine as a topical agent in nasal surgery, which was effectively used and popularized by Roe in 1887, which led to a major revolution in the concept of bloodless nasal surgeries.
William Ash in 1875 published his report on broken noses and their treatment using special forceps and external fixation, which is still relevant in today's era. Koenig, in 1886 used bone for the treatment of saddle nose deformity and also established the use of composite grafts.
The age of corrective esthetic rhinoplasty began in 1887, when John Orlando Roe, an Otolaryngologist from New York, described an intranasal operation confined to the tip of the nose so-called pug nose. He further went on to popularize his work and also stated the advantages of intranasal surgery over extranasal and thus avoiding any external scars.,
In 1891, he described the correction of angular deformities of the nose by subcutaneous operations and removal of a prominent bony hump, thus causing a reduction in size. This article was the first of its kind under corrective rhinoplasty incorporating “before and after” photographs [Figure 8] of three patients with successful intranasal operations.,
Heterogenous bone grafts were first successfully used and described by Monks in 1891 and later by Israel, in 1896. Weir, of New York in 1892, introduced a platinum prosthesis and celluloid obturators to replace deficient cartilage. In 1901, Joseph Goodale reported a successful transplantation of cartilage from the septum to correct nasal saddle deformity.,
The use of auricular conchal cartilage for grafting was successfully attempted by Suslov in 1897. Later, Jacques Joseph published his experiences and outcomes of reduction rhinoplasty in 1898.
He later went onto develop intranasal approach after successfully performing 100 surgeries in 1904 and also developed and described the technique of inserting implants intranasally, thus preventing external scars in his book Nasenplastik und sonstige Gesichtsplastik (rhinoplasty and facial plastic surgery), in which he described the use of external incisions on the nose, and thus he popularized the esthetic rhinoplasty and described modern techniques in 1932.
In 1934, Rethi of Hungary described a transcolumellar incision for tip projection. Sercer of Zagreb, Croatia, extended this incision with decortication of the nose in 1958, which provided the exposure of osseocartilaginous junction. His protégé, Padovan, followed this approach for septoplasty as well as cleft rhinoplasty and posttraumatic rhinoplasty in 1966 successfully and popularized it all over Europe.
Unquestionably, esthetic rhinoplasty was revolutionized and popularized by Roe, Weir and Jacques Joseph who used Leonardo da Vinci's principles of facial proportions, thus setting a path for future developments and innovation.
| Present Era|| |
During the modern era of rhinoplasty, there has always been an ongoing debate regarding the approach of rhinoplasty. Open rhinoplasty which began in India during the 7th century was well established in Europe during the past century. However, North Americans were introduced to this technique only in 1970 through the works of Goodman in Canada, and Anderson et al. in Louisiana, open rhinoplasty was popularized and is still taught in many residency programs.
Most surgeons now understand the wide range of uses for both endonasal and extranasal approaches and acknowledge the fact the surgeon's comfort with a certain approach is significantly important.
Rhinoplasty has changed considerably in the past decades from a standard reduction procedure to a highly differentiated problem-oriented procedure with reductions, relocations, and augmentation of tissues.
Many instruments were introduced between the 1960s and 1980s, which included a handheld saw, rasps, different osteotomes, and drills. With the introduction of Endoscope's in sinus surgery 1986, it created a new path of development for endoscopic-assisted rhinoplasty in the 2000s and is quite popular today.
Recently innovations in the powered instrumentation have expanded the niche for powered instrumentation by creating the opportunity for improvising precision and technical ease while minimizing tissue trauma. A new powered rasp for precision takedown or smoothing of bony hump offers a significant advance in surgical instrumentation.
With the development of technological advances, software systems have been developed that employs interactive computer graphics to simulate the surgical experience of rhinoplasty and allows the surgeon to learn and experiment within a model of nasal behavior.
For the past several years, several grafts have been used with increasing frequency during rhinoplasty procedure due to the developments of augmentation rhinoplasty. There have been a number of grafting materials available, including autogenous materials, homografts and synthetic or alloplastic materials.
The role of three-dimensional (3D) printing has expanded in diverse areas of medicine. This new technology has exciting applications in rhinoplasty. Digital Photography, morphing software, and 3D cameras have offered patients and surgeons advanced tools in rhinoplasty. It helps the surgeon in planning, intraoperative aid, thus offering more patient's satisfaction and better cosmetic results. 3D rhinoplasty is a novel advance and holds significant prominence in rhinoplasty.
Thus, rhinoplasty though one of the ancient surgeries has paved its way through decades and has eventually led to an emerging subspecialty in the field of otorhinolaryngology.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]