Larry S. Nichter, M.D., Raymond F. Morgan, M.D., and Mark A. Nichter, Ph.D., M.P.H.

“The operations whose object is to repair mutilations constitute one of the most brilliant triumphs of surgery.”

VELPEAU (1795–1867)

The Indian art and science of total nasal reconstruction comprise the first if not the most important chapter in the history of plastic surgery. Remarkably, centuries after their first use, the original Indian methods utilizing the cheek flap and median forehead flap for total rhinoplasty remain the basis for most reconstructive rhinoplastic procedures. The origins and diffusion of Indian rhinoplastic surgical procedures to the western world reveal the extent to which modern surgical procedures are indebted to their Indian forerunners.

Description of injury and disfigurement of the nose are commonplace in recorded medical history. Injuries are variously attributed to self­fliction, mutilation as a form of punishment, or a complex of disease states. The deliberate amputation of Lady Surpunakha’s nose in 1500 B.C. by Prince Lakshmana in India is the first recorded account of this practice. Accordingly, the mighty King Ravana arranged for the recon­struction of Lady Surpunakha’s nose by his physicians and thus documented the beginning of Indian nasal reconstruction.1

Traumatic amputation and destruction of the nose by 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 noc kart gaya,” for example, is a common expression connoting that “you have injured my feelings” but literally meaning “you have cut off my nose.”

The Indian tradition of nasal amputation was so strong that even statues had their noses lopped off during periods of political strife.1 The need for facial reconstruction and in particular nasal reconstruction historically set the stage for the development of the necessary surgical techniques and the birth of plastic surgery. A short historical review highlights major events causing the large number of nasal deformities and suggests the importance of original Indian methods.

Nasal Mutilation

Tolerance has rarely been given to those deformed by birth or traumatically mutilated. In early history, congenital defects of face or body, by and large, were eradicated by infanticide. Throughout India, China, Japan, Greece, Rome, and Mrica, infants were reportedly killed by exposure, poisoning, burning, drowning, or the sword.25 Until the nineteenth century it was not uncommon for Indian children born with physical defects to be either drowned in milk or poisoned by smearing opium and the poisonous datura alba or mundar plant (Asclepias gigantea) on the mother’s breast.25 Such infanticide may have been regarded as merciful.

Less merciful, however, was adult punishment through loss of face. From the beginning of recorded history amputating a person’s nose has been used to punish and humiliate, making the victim of such punishment a permanent social outcast despite his previous status, a member of the living dead. Records of both civil and military punishment reveal this treatment.

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. Sixtus Quintus of Rome (1521–1590) ordered nasal amputation of thieves and other rogues.17 In 1769–1770 Pritivi Narayan, the Ghoorka 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.”15 In recent times, too, the Da­coits of Northern India plundered a village and punished resistance by amputating the noses of their enemies. 1

Because in India the nose is considered the organ of respect and reputation, its loss by any means makes one shunned by the rest of society.27 Mutilation of the nose was practiced on women suspected of infidelity, on sexual offenders, and as a prime means of “mortal revenge.” Women accused ofadultery and thieves were the most common victims. This punishment is still practiced occasionally in India and Pakistan.

Whereas most of the nasal amputations in India occurred as a result of trauma, the majority of nasal mutilations in Europe were caused by the epidemic ravages ofdiseases like leprosy, smallpox, noma, lupus and especially syphilis. During the height of the syphilis epidemic in seventeenth century Europe, an estimated 15,000 prostitutes, outnumbering the men two to one, traveled with the troops of Wallenstein in the siege of Nürenberg in 1632.17

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. Two early methods still in use are the cheek flap and the median forehead flap.

The very earliest recorded treatment of the injured nose is actually found in the Egyptian Smith Papyrus, estimated to have been written about 3000 B.C. Hieroglyphs document treatment of the broken nose by nasal packing and external adhesive plaster. In India, however, evidence suggests that actual operative nasal reconstructive procedures were performed as early as the Vedic times (circa 3000 B.C.). In fact, the Rig Veda, a written hymn, mentions disfigurement of the nose as a form of punishment.

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.9

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.16 Based on an ecologic model, vitiated body humors, which we perceived as relation­ships between elements, are ascribed to be the active, if not the ultimate, cause of diseases. That is, diseases were thought to be caused by disturbances of a dynamic equilibrium.22. 32 Some treatments include medicines still used today, such as ephedrine and rauwolfia.

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 quotations from the Sushruta Samhita serve as an introduction to the tools necessary for the surgical craft at that time.18

In this science, the use of edged instruments is considered to be predominant … [They] are used for eight purposes—viz. (1) amputating; (2) openings; (3) scar; (4) puncturing; (5) exploring; (6) drawing; (7) evacuating; (8) sewing. A surgeon contemplating to operate in any of the above ways should first have ready the following: blunt instruments (forceps, etc.), sharp instruments, potential cauteries, virtual cauteries, catheters, horens, leaches, a dry gourd, cau­terizing needle, stuffing materials, strings, board, bandage, honey, ghee, fat, milk, oil, soothing decoc­tions, injections, lotions, fan, cold and warm water, a frying-pan, … able, steady, and attached servants. Let the patient be seated, who has taken very little food … The surgeon should stand with his face toward him and plunge his instrument … until matter comes out, and withdraw it, avoiding vital parts…. Boldness, rapidity of action, sharp instruments, operation without trembling, fear, or doubt are always praiseworthy of the surgeon operating…. The instruments should be made so that they … [are] of a good finish, strong, clean in appearance, with good handles whether they be sharp or blunt. Among these, the Svastike instruments ought to be about nine inches long; their mouths should be respectively like those of a lion, tiger, wolf, hyena, bear, elephant, cat, hare, antelope, crow, heron, dog, jay, vulture, falcon, kite, cock, bee, rat, mouse, bullock — each half being united to the other by a nail or the form of a lentil seed, being bent inward at the handles like the elephant-driver’s hook. (Figs. 1 and 2.)

Human anatomy, learned from cadaver dissection, filled the Sushruta Samhita, which also detailed operations for nasal reconstruction, cataract extraction, cesarean section, and even removal of stones from the bladder. Although the “Indian method” of nose reconstruction is now synonymous with the median forehead flap, the original Sushruta Samhita description of nasal reconstruction actually describes the cheek flap, which represents the first descrip­tion of the use of a pedicle flap. It is not presently known if the forehead flap was first used in Ayurveda, as most of the ancient Sanskrit texts have not yet been translated. In fact, it is estimated that over 1500 medical manu­scripts in Sanskrit have not been translated. 18 The following description from Sushruta Sam­hita presents the state of the art of partial and total nasal reconstruction.28

Rhinoplastic Operations

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 [licorice 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 deemend 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.

Indian Reconstructive methods in Greece, Rome, and the Middle East

In other parts of the world, the exact chro­nology of the appearance of the use of the cheek flap and the median forehead flap is unknown. The Western world remained ignorant of San­skrit medical texts until the eighteenth century when India had its first contact with Britain and initial translations were undertaken. Evidence exists, however, of a previous spread of Indian Ayurvedic medical knowledge by Buddhist mis­sionaries into Greece and Arabia. It is thought that Pythagoras (circa 500 B.C.) employed prin­ciples ofAyurvedic medicine. Further still, with avenues of trade set up beween Greece and India following the conquests of Alexander the Great, Ayurvedic medicine influenced the de­velopment and teachings of Greek medicine by Hippocrates and Galen.18 In fact, Alexander kept Indian physicians in attendance in his court.

Although it remains unclear when Indian techniques on nasal reconstruction first reached Italy, in Rome, Celsus (25 B.C. to 50 A.D.) was the first European to record techniques of clos­ing defects of the nose, lips, and ears by using adjacent tissues.13

In the fourth century A.D., Vagbhat, an Indian physician, recounts with more detail than the Sushruta Samhita the technique of cheek-flap rhinoplasty. In his book, Ashtanga Hridyans, he credits the technique to Maharishi Atreya. The following seven verses from his treatise are illustrative:

Do as follows for a clean (pure) person whose nose has been cut Having cut a pattern on a leaf to the size of the nose to be repaired, cut similarly with the pattern on the cheek. Protect the skin and flesh near the nose so that it remains his part (i.e. flap pedicle). Then suture the cheek with a sharp needle and cotton thread; and having incised the edge of the nasal opening turn in the outer skin. Then unite the strap of skin from the cheek, suturing it to the nose with care. Lift it with two tubes so that he may breathe easily. Then having moistened the wound with raw oil, sprinkle over it a paste of patanga and makhuka, and with other fine haemostatic pow­ders. Then having covered it with ghee and honey, keep a constant watch and subsequently treat the wound as required by the developments. Finally trim off the excess of tissues near the nostril and suture it carefully. If short make it up again. 1

In Vagbhat’s description, emphasis is placed on cutting the flap with accuracy, protecting the pedicle through which the flap obtains its blood supply, repair of the defect remaining after the flap is moved, and use of skin to provide lining. He reminds the surgeon to carefully approximate the cut edges of wound, and he recommends the use of topical hemostatic agents, intranasal splints, and adjustment of tissues in the postoperative period.1

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 center 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 which were later translated into Latin. These translations ultimately allowed the introduction of Ayurvedic medical and surgical knowledge into Western civilization.13 Certainly the most noteworthy Arabic physicians of that time, Rhazes and Aviceruna, often referred to the teachings of Sushruta.

Paulus Aegineta, a seventh century Greek physician, was also responsible for the integra­tion of Eastern medical and surgical practices into Western civilization. He summarized the medical literature current in his time in a seven-volume compendium. In the sixth book of the set, mention is made of the treatment of facial defects by rearrangement of adjacent healthy tissue.

Introduction of Indian Methods in 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 &ndash 1599) learned and popularized the procedure that came to be known as the “Italian method”16 (Figs. 3 and 4). 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. Published in 1597, two years before Tagliacozzi’s death at the age of 54, De Curlorum Chirurgia per Insitionem was the first text dedicated solely to the subject of plastic surgery.13 The importance of this treatise is confirmed by the appearance of the third edition in Frankfurt, Germany one year later (Fig. 5). Severe criticism, however, was directed posthumously at the author by contem­porary European surgeons. At times promulgation of the treatise was even prevented by Church and State.8

Development of the Forehead Flap for Nasal Reconstruction

India once again provided the knowledge and impetus for further development offacial reconstructive surgery, as advances were made in the ancient Indian Hindu art of total nasal reconstruction. Certainly there was a need for practitioners of this art. The Ayurvedic traditions of total nasal reconstruction has been practiced by the caste of the brickmakers and potters. 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 reconstruction17 (Fig. 6).

The source of development of the forehead flap for nasal reconstruction is unclear in Indian history, but has been performed since 1440 A.D. by the Mahrattas of Kumar, some Nepalese families, and the Kanghiara family of Kangra, India. The last surviving member of the Kanghiara family, Hakim Dina Nath, was a member of the Koomhar or potters caste and performed this operation during the twentieth century. Hakim Dina Nath claims that his family has been practicing the art of nasal reconstruction by this method since 1000 B.C.1, 2 This modification, known universally today as the “Indian method,” was practiced in secrecy and trans­mitted from father to son without written rec­ords. It was finally disclosed to the outside world in 1794 when the Madras Gazette, a journal in Bombay, printed an article revealing the family secret. Later texts, such as Brett’s Surgical Textbook published in Calcutta in 1840, also described the median forehead flap technique for total rhinoplasty, reaffirming the common practice of total nasal reconstruction by a tribe of Koomhars and potters living in the hills of Suttledge, long famed for their dexterity in executing this operation.

Introduction of Indian Methods to 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.17 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 oftotal nasal reconstruction while working in Madras, India.10, 18 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 persusal by plastic surgeons. 24 In his celebrated letter, “B. L.” describes the fate of Cowasjee, a bullock driver with the English army in the War of 1792. Having been captured by Tipu Sultan, his hand and nose were am­putated. His operation is described by “B. L.”:3, 24

Mr. Urban, A friend has transmitted to me, from the East Indies, the following very curious, and, in Europe, I believe, a known chirurgical operation, which has long been practiced in India with success; namely, affixing a new nose on a man’s face. The person represented in Plate 1 [Fig. 7] is now in Bombay. Cowasjee, a Mahratta of the caste of husbandman, was a bullock-driver with the English army in the War of 1792, and was made a prisoner of Tipu who cut off his nose and one of his hands. In the state of the Bombay army near Seringapatam is now a pensioner of Honorable East India Company. For about 12 months he has remained without a nose when he had a new one put on by a man of the brickmaker caste, near Puna. This operation is now common in India, and has been practiced from time memorial. Two medical gentlemen, Mr. Thomas Caruso and Mr. James Trindaley ofthe Bombay Presidency, have seen it performed as follows: A thin plate of wax is fitted to the stump of the nose, so as to make it a nose of good appearance. It is then flattened and laid on the forehead. A line is drawn around the wax, and the operator then dissects off as much skin as it covered leaving undivided a small slit between the eyes. This slit preserves the circulation until a union has taken place between the new and old parts. Cicatrix of the stump of the nose is next pared off, and immediately behind this raw part an incision is made through the skin, which passes around both alae, and goes along the upper lip. Skin now brought down from the forehead and, being twisted half round, its edge is inserted into this incision, so that a nose is formed with a double hold above, and with its alae and septum below fixed in the incision. A little Terra Japonica is softened with water, and being spread on slips of cloth, five or six of these are placed over each other, to secure the joining. No other dressing but this cement is used for four days. It is then removed, and cloth dipped in ghee (a kind of butter) are applied. The connecting slips of skin are divided about the twenty fifth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation the patient is made to lie on his back; and on the tenth day bits of soft cloth are put into the nostrils, to keep them sufficiently open. The artificial nose is secure and looks nearly as well as the natural one; nor is the scar on the forehead very observable after a length of time. Picture from which this engraving was made was printed in January, 1794 ten months after the operation. Yours &c., B. L.

The Indian Method Reaches the British Isles

Joseph Carpue (1764–1840), an English surgeon at the York Hospital in Chelsea, was probably influenced by this article and was, most likely, the first European to practice the “Indian Method” of nasal reconstruction utilizing the median forehead flap, presenting this technique in the European Surgical Honoratarium (Fig. 8). The following abstract and portions from his “Account ofTwo Successful Operations for Restoring a Lost Nose” published in 1816 are of historical interest:

On undertaking the first of the two cases to be hereafter narrated, I was induced to make such personal inquiries as were within my reach in this country, concerning the Indian method. I did myself the honor to write Sr. Charles Mallet, who had resided many years in India, who obligingly confirmed to me the report that this had been a common operation in India from time memorial; adding that it had always been performed by the caste of potters or brickmakers, and that though not invariably, it was usually successful. Mr. James Stuart Hall, a gentleman who [spent] many years in India, assured me that he had seen the operation performed, that it was of tedious length. From Dr. Barry, of Indian Service, I have learned that he had also seen the operation: that occupied an hour and a half, and was performed with an old razor, the edge of which being continuously blunted, and dissection was every moment reset. Tow was introduced to support the nose, but no attempt to form nostrils, by adding a septum, was made. I am obligingly informed by Major Heitland of the India Service that in India, several years ago, in the time of Hyder Ali, Mr. Lucas, an English surgeon, was in several instances successful in the operation, which he copied from the Hindu practitioners…. I have heard that about the year 1803, the nasal operation by the Indian method, was performed in London, without success. The patient, I am told, is still alive in India. I can add no more to the history of the Indian methods; but what has appeared is sufficient to rest the reader’s attention, both as it offers so great an improvement on the Tagliacotian practice, and illustrates the history of the operation in general. It cannot be otherwise, that this discovery of its existence in the distant regions of India, should awaken our curiosity more earnestly than before, as to place the date of its original use.

The remainder of the article presents operative details and documents the daily progress of his two patients after surgery.

Germany, France, and North America

Just two years later 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 (Fig. 9). 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 (Fig. 10). Suggestions were given to fold the distal end of the median forehead flap to form the columella, and to maintain patent nares with splints made of rubber tubing. 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 Journal29 (Fig. 11).

Communication between Europe and India continued to foster and improve the Indian art of total rhinoplasty. At the turn of the century, Keegan in his book on rhinoplastic operations documented reports of over 152 reconstructive rhinoplastic operations in Europe in addition to having personally performed 100 nasal reconstructive procedures in a five-year period while stationed in India.15 The most significant advances in total nasal reconstruction, however, occured through the reconstructive efforts of surgeons treating the injured of World Wars I and II

Summary

The Indian methods of total nasal reconstruction are integral parts of the origins of plastic surgery. Both found their births in the teachings of Sushruta six centuries before Christ. And now, even in the present state of the art, 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.

References