Plastic and Cosmetic Surgery Through the Ages

Cosmetic Surgery Magazine article, posted 2005

The word plastic comes from the Greek plastikos, meaning “able to be shaped or molded”. Although nasal surgery was mentioned in Egyptian Hieroglyphics, the earliest known treatise on the subject known as the Samhita was written by an Indian Susruta in about 600 B.C.

In India, prisons did not exist and crimes were usually punished by fines – but in more severe infractions, such as adultery, the nose or ears were amputated. Susruta describes the reconstruction of a nose using skin from the cheeks.

Another method of unknown origin entailed using a flap of skin brought down from the forehead. Reeds were inserted so that during the healing, nostrils would be formed. Eventually the forehead completely healed, leaving only an indentation.

These texts were translated into Arabic and incorporated into Western surgical practice during the time of Aegineta (625-690 A.D.) in the Roman Empire.

By 1450, a Sicilian family known as Branca was using forehead flaps to reconstruct noses. Antonio Branca used a flap of skin from the upper arm. During the Renaissance, Flemish anatomist Dr Andreas Vesalius published the landmark anatomical text Fabrica (On the Structure of The Human Body) in 1543. It was the first manual of human anatomy with clear and detailed instructions. Frenchman Ambroise Pare (1510-1590) detailed reconstructive war surgical procedures after learning his craft on the battlefield as a surgeon in the French Army.

The Italian surgeon Gaspare Tagliacozzi described a procedure for nasal reconstruction in his textbook published in 1597 in Venice. He had spent years practicing his techniques during the syphilitic 16th century. Syphilis had become an epidemic throughout Europe, following the Spanish expeditions to the Americas in 1492.

The first recorded outbreak was in Naples in 1493 when the French conquered the occupying Spanish. Initially, the new scourge became known as the French Pox. But soon, as Ray Porter details in his “The Greatest Benefit to Mankind,“ the Dutch called it the Spanish disease; the Russians called it the Polish disease; the Siberians called it the Russian disease; the Turkish called it the Christian disease; the Indians and Japanese called it the Portuguese disease; the Portuguese called it the Castillian disease; and about 200 years later, the Tahitians called it the British disease, blaming it on Captain Cook.

Dr. Tagliacozzi’s procedure was not, however, for the faint-hearted. First, a flap of skin was partially cut from the upper arm. When enough healing had taken place to ensure that the tissue remained living, a second operation was performed, in which the flap was shaped into a rudimentary nose and attached to the face. After about two weeks (and presumably a lot of arm ache) the new nose was finally severed from the arm. Then the doctor operated yet again, this time to refine the contours and general appearance. The entire procedure took from 3 to 5 months. Presumably it was accompanied by considerable pain, as anesthetics were virtually unknown in those days.

Lack of anesthetics, combined with the notorious risk of infection, encouraged some to seek less painful solutions.

In 1570, Tycho Brahe, the noted Danish astronomer, replaces his missing nose with a shiny metal alloy prosthesis. The story goes he lost his natural nose in a duel.

In 1794 in India a story was published in the Madras Gazette (and later in the Gentleman’s Magazine, London) about an Indian bullock driver with the English army named Cowasjee, who had his nose and one hand amputated by Sultan Tippoo during the war of 1792. The nose was reconstructed one year later by a man of the brick maker caste near Poonah. The operation was not uncommon in India and had been practiced from time immemorial. A thin plate of wax was fitted to the stump of the nose to make a nose of good appearance. It was then flattened and laid on the forehead where a line was drawn around it. The forehead flap was cut with a razor, turned down and inserted into an incision to form a nose. The connecting flap of skin was divided about the 25th day.

In 1814 in London, Joseph Carpue F.R.C.S. used the Indian method of nasal reconstruction on an Officer in His Majesty’s Army at York Hospital, Chelsea. The operation took a quarter of an hour (9 minutes dissection, 6 minutes ligatures) and the patient observed: “It was no child’s play and extremely painful, but there was no use in complaining.” Carpue wrote that the new nose has every appearance of a natural nose. The forehead was healed in three months.

In 1845 in Germany, Dieffenbach described the first aesthetic reduction of a large nose. He used external incisions.

In 1887 John Orland Roe, an ear, nose and throat surgeon from Rochester, New York, reported three cases in which he reduced the tip structure of the nose through the nostrils. He described the procedure in “The Deformity Termed Pug Nose and its Correction by a Simple operation.“ In 1891, Roe described correction of the entire nose for four cases, reducing the bony and cartilaginous hump by operating with a chisel through the nostrils. His publication “The Correction of Angular Deformities of the Nose by Subcutaneous Operation“ included pre- and post-operative photographs.

In 1898 Jaques Joseph, the modern father of rhinoplasty (nose surgery) and an orthopedic surgeon from Berlin, performed his first cosmetic operation on a boy with prominent ears. The patient was very appreciative and convinced Joseph of the value of aesthetic surgery. He performed his first rhinoplasties with external incisions and later adopted incisions within the nostrils. He popularized aesthetic rhinoplasty and described the basis of modern techniques in an excellent book published in 1932, “Nasenplastik und sonstige Gesichtsplastik.“ He was the second surgeon to use pre- and post-operative photographs in his work.

In World War I a large number of patients with gunshot wounds to the face were treated in military hospitals. Modern cosmetic plastic surgery has evolved from reconstructive war surgery.