| | | | | The Rhinoplasty Renaissance
Nasal mutilation, the birth of Rhinoplasty, and Sushruta’s gift to Beverly Hills | Rohan GuptaAcademic Writing
Dr. Neeraja Sankaran |

Table of Contents The Rhinoplasty Renaissance 1 Nasal mutilation, the birth of Rhinoplasty, and Sushruta’s gift to Beverly Hills 1 Abstract 1 Meanings Attached To Cutting-Off Of The Nose Around The World 1 Cutting Off The Nose In South And West Asian Mythology And Folklore 2 Ancient Indian Methods For Total Nasal Reconstruction 3 Indian Reconstructive methods in Greece, Rome, and the Middle East 5 Indian Method Reaches Italy 5 Development of the Forehead Flap for Nasal Reconstruction 6 The Indian Method And Great Britain 6 The Neo-Traditional ‘West’ 7 Summary 8

The Rhinoplasty Renaissance
Nasal mutilation, the birth of Rhinoplasty, and Sushruta’s gift to Beverly Hills
Abstract
“The operations whose object is to repair mutilations constitute one of the most brilliant triumphs of surgery.”
— Alfred-Armand-Louis-Marie Velpeau (1795-1867), French anatomist/ surgeon

Bodily mutilations, such as nose cutting and disfigurement are commonplace in recorded medical history from different cultural settings.
In fact, traumatic amputation, and destruction of the nose either by intent or disease are so commonplace in history that they have insinuated themselves into the language of many cultures via idiomatic expressions suggestive of their impact. In English, for instance, phrases such as “loss of face” and “cutting off the nose to spite the face” suggest the humiliation associated with facial disfigurement. In Urdu and Punjabi, expressions relating to the nose occur frequently. “Mera naak kat gaya,” for example, is a common expression connoting that “you have injured my pride” but literally meaning “you have cut off my nose.”

Meanings Attached To Cutting-Off Of The Nose Around The World
Psychoanalytic perspectives based on Freudian categories assume correlations between the nose and sexual pleasure. Psychologists like Kakar have interpreted nose-cutting as symbolizing clitoridectomy or female castration, as well as male castration (Kakar, p.99). In the Freudian sense, it could also be equated with a sense of male inferiority, or a fear of sex complex following the “loss of face” (aberu) as seen in Iranian culture.
Actually, in many cultures, a person’s nose—a key organ of sense—was cut off as a severe form of punishment. As the nose is a highly conspicuous feature, and a very noticeable part of one’s physiognomy, this atrocious form of violence was tantamount to outlawing that person. The practice has nothing in common with other well-known forms of body mutilation such as circumcision, knocking out of teeth, tattooing etc.
The barbaric act of disfiguring victims, thereby turning them into “ungestalten” (a medieval term still used in Modern German, which can be roughly translated to mean “freak”, and equated with the Latin “deformitas”) is known since antiquity. In Ancient Egypt, adulteresses were proscribed in the same manner. Likewise in Europe during the 14th-15th centuries, adulterers, homosexuals, and prostitutes were mutilated by having their nose cut off. In Spain, their nostrils were slit open. The same gruesome punishment awaited a seducer in Russia, if he copulated with his fiancé, even with consent.
Examples abound in Asian and European literature. In the ninth century the Danes slit the noses of Irishmen who could not pay the annual levied tax of one ounce of gold. In 1769–1770, Prithvi Narayan, the Gurkha King of India, ordered the amputation of nose and lips of all 865 male inhabitants in the recently captured city of Kirtipoor, Nepal. Only musicians who played wind instruments were excluded. Adding insult to injury, he changed the city’s name to Naskatapoor, which means “city without noses.”

Cutting Off The Nose In South And West Asian Mythology And Folklore
The severed nose appears as a powerful narrative motif in oral tradition as well as factual reality. A famous case of nose cutting appears in the Ramayana where Lakshmana, the younger brother of Rama, chops off the nose as well as the ears of cannibal giantess Surpanakha—sister of the demon-king Ravana. The reason behind this mutilation was that she felt a strong desire for Rama and had tried to kill his wife Sita.
Ancient Indian Methods For Total Nasal Reconstruction
Given the common occurrence of nasal amputation, Indian methods for total nasal reconstruction were developed early and to a large degree reflect the origin of plastic surgery, as we know it today.
The first detailed description of surgical replacement of the amputated nose, found in the classical text on Indian surgery, the Sushruta Samhita (circa 600 B.C.), has its early origin in the four Vedas. These four texts, the sacred source of Hindu “divine knowledge,” are sets of hymns written in an old form of Sanscrit attributed to the Aryans who invaded India from Persia and Caucasus in approximately 1500 B.C. Formed as an eclectic compendium of magicoreligious and ethnoscientific information, the Vedas provided the foundation for both the Brahmanical religious system and the Ayurvedic medical tradition. The Rig Veda (circa 1500 B.C.), the original set of Vedic hymns from which the other Vedas are derived, and the Atharva Veda, of later origin, are revered as the roots of Ayurveda, the classical system of Indian health science.
Two seminal texts, one on medical diagnosis and the other on surgery, focus on the principles of Ayurveda. The first, the Charaka Samhita, draws a comparison between the microcosm of the body and the macrocosm of the universe.
The second text, the Sushruta Samhita, incorporates detailed and specific descriptions of surgical tools and operative techniques taught to Sushruta by Lord Dhanwantri, a physician to the gods. The following description from Sushruta Samhita presents the state of the art of partial and total nasal reconstruction.
Now I shall deal with the process of affixing an artificial nose. First, the leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped off part, should be gathered, in a patch of living flesh, equal in dimensions to the preceding leaf should be sliced off (from down upward) 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 with a bandage decent to look at and perfectly suited to the end for which it has been employed (Sadhu Vandha).
The physician should make sure that the adhesion of the severed parts has been fully affected and then insert two small pipes into the nostrils to facilitate respiration, and to prevent the adhesion flesh from hanging down. After that the adhesion part should be dusted with powders of Pattanga [red sandal], Yashtimadhukam [liquorice 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. Clarified butter should be given to the patient for drink, and he should be anointed with oil and treated with purgatives after the complete digestion of the meals he has taken, as advised [in the books of medicine].
Adhesions should be deemed complete after the incidental ulcer has been perfectly healed up while the nose should be again scarified and bandaged in the case of semi- or partial adhesion. The adhesioned nose should try to be elongated 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.
(Figs. 1 and 2 below illustrate the blunt and sharp instruments used by Sushruta)

Indian Reconstructive methods in Greece, Rome, and the Middle East
In other parts of the world, the exact chronology of the appearance of the Indian method remains unknown. The western world remained ignorant of Sanskritic medical texts until India had its first contact with Britain in the eighteenth century. Evidence exists, however, of a transmission of Indian Ayurvedic knowledge by Buddhist missionaries into Arabia and Greece. Pythagoras (circa 500 B.C.) is said to have employed Indian principles of medicine as propounded by Sushruta. Further still, with avenues of trade set up between Greece and India following the conquests of Alexander the Great; Ayurvedic medicine influenced the development and teachings of Greek medicine by Hippocrates and Galen (McDowell, 1977). In fact, Alexander kept Indian physicians in attendance in his court.
The Arabs and Nestorians probably shared an important role in further transmitting surgical knowledge from India to the Western world. The Persian Hospital and School of Medicine at Gondi-Sapor (sixth to tenth centuries A.D.), the great centre of learning in that era, allowed for free interchange between Hindu, Greek, Jewish, Nestorian, and Persian scholars. Here learned Arabians shared eighth century A. D. Arabic translations of the Sushruta Samhita that were later translated into Latin. These translations ultimately allowed the introduction of Ayurvedic medical and surgical knowledge into Western civilization (Gnudi, 1976). Certainly the most noteworthy Arabic physicians of that time, Rhazes and Aviceruna, often referred to the teachings of Sushruta.

Indian Method Reaches Italy
The above-mentioned events and documents probably provided the impetus for similar work in other countries. So, when in the fourteenth century, Branca de Branca, Senior, a layman in Sicily, became celebrated for his surgical abilities in the art of total nasal reconstruction, it is not surprising that his technique duplicated that described by that of the Sushruta Samhita some 2000 years earlier.
Antonius Branca, influenced by his father’s ability, experimented and was thought to have developed a new technique for total nasal re­construction described in 1430 A.D., using a flap of tissue taken from the arm. This method was practiced and kept alive mainly through the four members of the family of Vinaeo di Maida in Calabria, who reconstructed noses, lips, and ears. It is from this family that Gaspare Tagliacozzi of Bologna (1545-1599) learned and popularized the procedure that came to be known as the “Italian method”—a lengthy and tedious operation, consisting of six separate steps, the Italian method was successful enough to remain in popular use until World War I.

Development of the Forehead Flap for Nasal Reconstruction
The Ayurvedic tradition of total nasal reconstruction has been practiced by the caste of the brickmakers and potters for centuries. A brickmaker or potter as a surgeon is not so surprising, as their profession required manual dexterity. Furthermore, even men of great ability were prisoners of their respective caste. Indian surgical principles, tools, and techniques as espoused by Sushruta and Vagbhat continued to be passed down from father and son. Techniques commonly used special cements, cotton suture, or ant heads to close wounds. Newer tools and procedures were improvised when the need arose. At one time, free grafts of skin taken from the buttocks were applied to raw wounds. In time, the median forehead flap was developed for the purpose of total nasal reconstruction (Davis, 1941).

The Indian Method And Great Britain
European interest in rhinoplasty was renewed during Great Britain’s occupation of India. Although the East India Company was established in the 16oos, British influence was not prominent until the middle 1700s. The presence of the British was not taken kindly by many of the leaders of India, particularly Tipu Sultan, ruler of Mysore who violently opposed British control of southern India. To this end, he attempted to cut off food and supplies to the English troops under Cornwallis by attacking the Maharatta bullock drivers who transported needed grains to the British. The Sultan gave rewards for each nose, ear, or bullock brought back after a raid. Little did Tipu Sultan know that his acts would indirectly spur intense interest in nasal reconstructive surgery.
This may be partly attributed to a “Letter to the Editor” found in the Gentleman’s Magazine, in London, 1794. Although signed simply with the initials “B. L.” there is little doubt that these belong to Cully Lyon Lucas, an English surgeon who learned the practice of total nasal reconstruction while working in Madras, India. Although its content was published in a Bombay journal seven months previously, it was the English version that was responsible for the renaissance of nasal reconstructive surgery. The letter and accompanying comments were published in 1971 for perusal by plastic surgeons (B.L., 1794).

Illustration from the celebrated 1794 “Letter to Editor” responsible for the western spread of the “Indian Method” for total nasal reconstruction.
Illustration from the celebrated 1794 “Letter to Editor” responsible for the western spread of the “Indian Method” for total nasal reconstruction.
The Neo-Traditional ‘West’
In 1818, Carl von Graefe’s book Rhinoplastik, the first devoted to rhinoplasty, was published in Berlin. In it were listed 55 articles and books on the subject including Carpue’s work. The interest of the medical profession and laymen alike was aroused. Many surgeons in Europe and later in America were encouraged to attempt to under­take similar total nasal reconstructions using Indian methods. The most notable reviews of such early surgical trials include those of Delpech (1824), Labat (1834), Blanden (1836), Dieffenbach (1829–1834), Listen (1837), Zeis (1838), Velpeau (1839), Serve (1842), Von Aiman and Baumgarten (1842), and Jobert (1849). These forerunners of plastic surgery advanced the “Indian method” for rhinoplasty and offered modifications to minimize complications. The first reported case of total nasal reconstruction in North America utilized the “Indian method” and was reported in 1837 by Warren in the Boston Medical and Surgical Journal.

Communication between Europe and India continued to foster and improve the Indian art of total rhinoplasty.

The first total nasal reconstruction in North America. This was performed in 1837 by Warren in Boston using the ancient ‘Indian Method’.

Summary
The art of nasal reconstruction is well established in history dating back to 600BC in India. Advances have been made during the past 2 millennia in India, Europe, and America: however most of the refinements leading to contemporary techniques found their births in the teachings of Sushruta six centuries before Christ. And now, even in the present state of the art—the widespread way in which its practised from Beverly Hills to the beaches of Rio, we still rely heavily on the same techniques of total nasal reconstruction as handed down for thousands of years by Sushruta and the legendary clay potters of India.

Bibliography
Almast, S.: History and evolution of the Indian method of rhinoplasty. In Sanvenero-Rosselli, G. (ed.): Transactions of the fourth international congress of plastic and reconstructive surgery. Rome, 1969. Amsterdam, Excerpta Medica Foundation, 1969.
Baker, S. R.: Principles of Nasal Reconstruction, Second Edition
B. L.: Letter to editor. Gentleman’s Magazine, 891, October 1794.
Blair, L., and Shalmon, M.: Cosmetic Surgery and the Cultural Construction of Beauty, 2005
Carpue, J.: An account of two successful operations for restoring a lost nose. (From The Classic Reprint.) Plast. Reconstr. Surg., 44:67, 1969.
Graefe, C.: Rhinoplastik. Berlin, Mit 6 Kupfertafeln, 1818.
Gnudi, M., and W~bster, J.: The Life and Times of Gaspare Tagliacozzi. Los Angeles, Zeitlin and Ver Brugge, 1976.
Frembgen, J. W.: Honour, Shame, and Bodily Mutilation. Cutting off the Nose among Tribal Societies in Pakistan, 2006
Sushruta: Sushruta Samhita. In Bhishagratna, K.: An English translation of the Sushruta Samhita, based on original Sanskrit text. Calcutta, Bose, 1907.
Whipple, A.: The Medical School and Hospital of Gondi-Sapor and Its Influence on Arabian Medicine. Proceedings of the Charaka Club, New York, 9:95-110, 1938. *