Matthew Turner
Hershey, Pennsylvania, United States

From around 1000–800 BC, a golden age of medicine dawned in ancient India, where ayurveda, the “science of life,” flourished.¹ At the heart of this revolution was the legendary physician Sushruta, whose writings in the famous Samhita describe surgeries from cataract removal to treatment of bladder stones, diseases including diabetes mellitus and tetanus,² and over 100 surgical instruments.¹ Today, Sushruta is best known for his unprecedented description of ancient rhinoplasty.¹

In the Samhita, Sushruta describes the technique:

The physician… slices off [a piece of the patient’s] cheek a piece of skin of the same size [as the destroyed nose] … after scarifying the stump of the nose with a knife, he wraps the pieces of skin from the cheek carefully all around it and sews it at the edges… then he inserts two thin pipes in the nose (in the position of nostrils) to facilitate respiration and prevent flesh from collapsing.¹

After several weeks of allowing the skin to heal while routinely dressing and cleaning the nose with various herbs, “when the healing is complete and parts have united, the connection with the cheek is removed.”¹ This method of nasal repair using an adjacent flap of skin from the cheek is a remarkably modern technique.¹

While Sushruta’s rhinoplasty was unprecedented, nasal trauma was well known in the ancient world. The Edwin Smith Surgical Papyrus, dating some 2,000 years before Sushruta, describes ancient Egyptian techniques of treating nasal injuries—typically with simple manipulation followed by plugs of linen or other materials as absorbents.³ Rhinectomy, also known as nasal amputation, was also a common punishment to humiliate adulterers, thieves, and prisoners of war.⁴ Although rhinectomy was found across many civilizations—the Byzantine Emperor Justinian II Rhinotmetos, “the slit-nosed,” famously lost both his throne and his nose in a palace coup at the age of twenty-six and returned to power a decade later⁵—it was particularly prevalent in Indian civilization. The epic poem Ramayana from around 1500 BC describes the evil Lady Supanakha tempting the young and virtuous Prince Rama. She is discovered by Rama’s brother Lakshan, who cuts off her nose to foil her disguise and reveal her true evil nature to the world. Interestingly, the Demon King Ravana later has his physicians reconstruct Lady Supankha’s nose—the mythical beginnings of Indian rhinoplasty.²

Outside of myth, rhinectomy was common in ancient India. Rama and Lakshan’s example appeared to provide divine sanction for the custom, which was often enacted as a judicial punishment.³ Those who had suffered this punishment had a special designation: nacta (for males) and nacti (for females), an especially shameful connotation.² Outside of the judicial sphere, rhinectomy was also common in warfare. In 1770, when King Pritivi Narayan finally conquered the city of Kirtipoor in Nepal after a prolonged and bloody siege, the furious king had the noses and lips of all 865 surviving male inhabitants amputated. He then mockingly changed the city’s name to Naskatapoor, “the city without noses.”²

In such an environment, there was a great need for rhinoplasties. Most Indian rhinoplasties were performed by the Koomas, a group sometimes described as a “low caste of priests,”⁴ although they have also been described as potters.² In the region of Kangra, a family of famous surgeons known as the “Kanghiaras” performed rhinoplasties for centuries, passing down the art of rhinoplasty from father to son in strict secrecy.² Gradually, Indian rhinoplasty transitioned from using skin flaps from the cheek to skin flaps from the forehead; however, the precise date of this transition remains unknown.²

It appears likely that Sushruta’s methods eventually traveled to medieval Europe, where they may have been copied by a number of Italian surgeons.¹ However, European interest in plastic surgery eventually faded away.¹ This all changed when plastic surgery came back to the attention of Western medicine in 1794. In the October issue of The Gentlemen’s Magazine and Historical Chronicle of London, a British surgeon described a procedure that he had witnessed in India for reconstructing the amputated nose of a bullock driver named Cowasjee.³ The technique—using a flap of skin from the face to reconstruct the nose—was almost identical to Sushruta’s description, with one key difference: instead of using a skin flap from one of the patient’s cheeks, the flap was taken from the forehead.³ “This operation is now common in India,” the author wrote, “and has been practiced from time immemorial.”²

The article encouraged a newfound fascination with plastic surgery in the European world. In 1814, after nearly twenty years of practicing on cadavers and waiting for the right patient, Dr. Joseph Carpue announced that he had successfully replicated the “Indian technique” described in the 1794 article on two British officers—one that had lost his nose due to toxic symptoms from mercury poisoning, and another that had been mutilated by a sword-blow.³ “My God, there is a nose!” one of the officers famously cried out when the surgery was complete.⁴ Carpue’s account of the two surgeries, widely reproduced in An Account of Two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead, laid the groundwork for a new age of plastic surgery in the West.³

Nearly 3,000 years after his death, Sushruta’s medical genius laid the foundation for much of reconstructive surgery today. It is no surprise that he is still known as “the father of plastic surgery.”¹

References

1. Sorta-Bilajac I, Muzur A. The nose between ethics and aesthetics: Sushruta’s legacy. Otolaryngology—Head and Neck Surgery. 2007 Nov;137(5):707-10. https://doi.org/10.1016/j.otohns.2007.07.029
2. Brain DJ. The early history of rhinoplasty. Facial plastic surgery. 1993 Apr 1993;9(02):81-8.
3. Whitaker IS, Karoo RO, Spyrou G, Fenton OM. The birth of plastic surgery: the story of nasal reconstruction from the Edwin Smith Papyrus to the twenty-first century. Plastic and Reconstructive Surgery. 2007 Jul 1;120(1):327-36. DOI: 10.1097/01.prs.0000264445.76315.6d
4. Mazzola IC, Mazzola RF. History of reconstructive rhinoplasty. Facial Plastic Surgery. 2014 Jun;30(03):227-36. DOI: 10.1055/s-0034-1376868
5. Laes C. Power, Infirmity and “Disability”: Five Case Stories on Byzantine Emperors and Their Impairments. Byzantinoslavica-Revue internationale des Etudes Byzantines. 2019;77(1-2):211-29.