History of Facial Plastic Surgery

HISTORY OF FACIAL PLASTIC SURGERY

 

Cosmetic Surgery had its beginnings at the end of the nineteenth century. At first, the
morality of people willing to undergo such surgery was questioned, but with time, the
procedure gradually became more acceptable.

 

There were many factors affecting the growth of cosmetic surgery. The development of
general anaesthesia was a key issue since, until the 1920’s, dripping Ether onto a rag
covering the patients face was the most one could expect. The discovery of the first
antibiotic and Sulfanamide, in the 1930′ s was also a major factor, as the risk of infection in
such operations was high. Antibiotics became more widely used after World War II. Most
importantly perhaps, surgeons merely lacked knowledge or the appropriate techniques
needed to perform effective cosmetic surgery. With the development of general
anaesthesia, antibiotics and new techniques, reliable operations and instruments could
then be designed to accomplish cosmetic changes and reduce the risks involved.
Throughout its history, cosmetic surgery has always attracted opportunists; surgeons
seeking a quick and easy profit. At first, people were keen to believe in the promise of
youthful looks and were prepared to pay handsomely for it. In the early days, patients
seeking cosmetic surgery had merely wanted scars concealing, but by the 1950’s women
were demanding their noses to be reshaped, purely to be in keeping with fashion and the
popular image of beauty.

 

Reputable cosmetic surgeons are firstly general surgeons, plastic surgeons or
otolaryngologists familiar with the body in general. They are therefore able to manage
any surgical complaints which might arise. Traditionally, the best surgeons have actually
been trained as reconstructive surgeons, helping patients to look normal.


RHINOPLASTY


One’s nose draws the observer’s eye because of its prominent position in the middle of
the face. Surgeons have realized the anguish an obtrusive nose can cause to its owner
and have developed ways to solve it.

Surgeons at first had to experiment in altering the shape of the nose. They trimmed nostrils
that were too wide, elevated drooping tips and flattened humps of bone and cartilage to
smooth humped noses. The real challenge was not the operation itself but leaving no
obvious scars afterwards.


RHINOPLASTY: M.B. BIZRAH HISTORY OF FACIAL PLASTIC SURGERY

Johann Friedrich Dieffenbach (1794-1847), a Prussian
surgeon, made the first recorded attempt to reshape a nose.
He removed a wedge of flesh in order to raise a drooping
tip and generally reduce the size of the nose. To slim the
thick skin of a man’s nostrils, Dieffenbach removed wads of
skin using a punch, an instrument similar to the tool used
by a leather or metal worker.


John Orlando Roe (1848-1915), an ear, nose and throat
surgeon from Rochester, New York, first addressed the Johann Friedrich Dieffenbach
problem of the elimination of all visible scarring. He
recognized the importance of making the nose blend with the rest of the face and he proposed
John Orlando Roe
operating on the nose through incisions hidden within the
nostrils. Using this approach, he showed how he could reshape
a pug nose, a deformity of the nasal tip resembling a dog’s
stubby snout. Roe reduced an entire nose by removing excess
bone and cartilage through an unobtrusive internal incision.
The anaesthetic Roe used was cocaine. He applied it to the
interior of the nose and injected it under the skin. Roe was
unaware of the dangers of cocaine and was using it for his
patient’s comfort. He appreciated the psychological benefits of
cosmetic surgery. A well performed operation could relieve a
patient’s embarrassment by eliminating a disfiguring feature.
Karl Koller (1857-1944), had introduced the use of cocaine in eye surgery while an intern
at Vienna’s General Hospital. The world famous ENT Clinic in Vienna, Allgemeines
Krankenhaus, was founded in 1884 by a surgeon unable to
gain entry into general hospital. Robert Barany who received
a Nobel Prize and George Von Bekesy practised at this clinic.
Robert Fulton Weir (1838-1927) of New York, introduced the
subtle technique of reducing and refining a large, distorted
nose. Weir operated through incisions hidden within the
nostrils. To reduce the width, Weir chiselled the bones loose,
moved them inward, and secured them by piercing them with
a needle that was prevented from slipping by a metal shot
Robert Fulton Weir


HISTORY OF FACIAL PLASTIC SURGERY RHINOPLASTY : M.B. BIZRAH



placed at either end. He also reported on how he narrowed the flaring nostrils of the
wide, flat nose of an adult patient whose deformity typically accompanies a cleft lip. It is
now routine to use Weir’s procedure of removing a wedge from the base of each nostril,
then rolling the nostril inwards.


In Weir’s paper “On Restoring Sunken Noses” he identified the patient who is never
satisfied with results and demands operation after operation, searching for perfection.

Jacques Joseph
Jacques Joseph (1865-1934) Berlin, performed his first
nose operation in 1896. Joseph tackled the problems of
reducing a large nose while leaving as few offending scars
as possible. He could shorten the nose, reduce its hump,
straighten it and make the nostrils smaller by using
incisions in the skin. Joseph performed the surgery
through the inside of the nostrils. He had great success
and, like his techniques, the saws, chisels and clamps that
he devised for surgery are still in use today. Joseph was
originally trained in Orthopedics. At that time cosmetic
surgery was considered unimportant and unethical at
Joseph’s University. He was temporarily suspended from
his academic post for his unorthodox activities. He was not discouraged by this and
continued to develop operations to correct abnormal features. In the year 1898, Joseph
presented his procedures to the Medical Society of Berlin, where many local and American
doctors were attending. He used intranasal incisions, removed nasal humps, performed
lateral osteotomies and employed ivory for augmentation. (Joseph used to obtain ivory
from a nearby piano factory). Joseph’s outstanding work enabled him to develop a
worldwide reputation and people came from far and wide
to have their rhinoplasty performed by him. Even more
importantly, surgeons travelled great distances too in
order to learn from him. Joseph, who was referred to as
“Joseph Noseph”, specialized in rhinoplasty but also
performed facelifts, otoplasty and general plastic surgery.
In January 1934, Joseph performed his last rhinoplasty on
the 16-year-old daughter of a Munich restaurateur. When
Hitler rose to power, Joseph fled from Berlin to Prague.
After his death, Joseph’s students brought his work to the Joseph Safian
RHINOPLASTY : M.B. BIZRAH HISTORY OF FACIAL PLASTIC SURGERY
Safian’s Surgical Instruments and
leather carrying case
attention of English-speaking surgeons. Among
Joseph’s students were Gustave Aufricht, a Hungarian
surgeon and Joseph Safian, both of whom became
reputable as facial plastic surgeons in the United States.
Safian was a careful and conservative surgeon who
concentrated on how to avoid mistakes and how, if
they were made, to correct them. Aufricht modified
the Weir’s incision, and devised the Aufricht retractor
which is still used in every rhinoplasty today.
Today surgeons have more control in changing the shape of the nose without leaving
visible scars. There are many new instruments available, special scissors and saws and a
retractor, complete with its own beam of light to name but a few. Surgeons have learned
how to produce a beautiful nose by augmenting the tip with
tiny grafts of cartilage taken from the ear or nasal septum.
They have also learned that operating on the nose by using
external incisions and peeling back the skin to expose the
skeleton beneath produces more pleasing results as the
incisions fade with time.


Fomon (1889-1971), Cottle (1898-1981) and Goldman (1898-
1975) all developed further the Joseph and Safian techniques
and greatly contributed to the teaching of rhinoplasty by their
courses, books, articles and instruments. They trained
Samuel Fomon
generations of American and overseas surgeons in the forties,
fifties, sixties and seventies. Irving Goldman published seventy
Maurice H. Cottle
eight articles. His famous annual
rhinoplasty course, continues to
this day, at Mt. Sinai Hospital, run
by his students. The Goldman’s
tip technique, to improve tip
projection, is still practised today
by many facial plastic surgeons.
Its concept is the basis for the
newly modified and developed tip procedures. In 1975, Jack
Sheen added the use of the autogenous triangular shield tip Irving Goldman


HISTORY OF FACIAL PLASTIC SURGERY



Tony R. Bull
graft in order to enhance tip
projection and definition.
The use of Sheen grafts with
the modification of the
Goldman’s tip (preservation
of lateral crus) have
revolutionized the results of
our rhinoplasty.
R. W.H. Kridel
M.E. Tardy, Jr.
RHINOPLASTY : M.B. BIZRAH
Gaylon McCollough
Robert Simons
The master rhinoplasty surgeons of the last twenty years (1980-2000) such as Robert
Simons, Gaylon McCollough, M.E. Tardy, R.W.H. Kridel, Rollin Daniel, Webster, Dean
Toriumi of the United States, and Tony Bull from the United Kingdom and others, have
greatly contributed to the advances in our techniques today. The Tony Bull Course,
London, has been operating for the last twenty years. The participants are surgeons from
all over the world who are wishing to consider a career in rhinoplasty.


EARS


Giovanni Bathista della Porta, a sixteenth-century Neopolitan naturalist and philosopher,
described a perfect ear as being neither too long nor too short. Johann Casper Lavater, the
eighteenth century Swiss pastor who popularized the belief that external appearance is
governed by inner moral qualities, devoted only three pages to ear size and shape and
never once mentioned the criteria for judging the beauty of an ear. It is only in recent times
RHINOPLASTY: M.B. BIZRAH
Giovanni Bathista della Porta


HISTORY OF FACIAL PLASTIC SURGERY


that ears have been operated on to improve their aesthetic
quality. Before this ears were only reconstructed if they
had been partially damaged or completely destroyed.
Ears placed closed to the head are recognized as desirable
and surgeons have sought ways to make them flat. If
one is unfortunate enough to
have ears set at a right
angle to the skull one is
prone to be taunted as
stupid or mean.
Edward Talbot Ely (1850-1885), Otolaryngologist at the
Manhattan Eye and Ear Hospital pioneered the method
for reshaping ears. However, this was not a problem
free method since cutting
William Henry Luckett
out a strip of cartilage to
flatten the ears left them
Johann Casper Lavater
with too sharp a crease. William Henry Luckett (1872-1929),
New York, was the first to decide exactly what twist of
anatomy made the ear protrude. A normal, visually
pleasing ear gently folds back on itself and Luckett
speculated that the protruding ear lacked such a fold. He
set out to create a fold in the ear and after doing so he
secured it with a line of stitches so that the ear was
permanently rolled back toward the skull. Luckett took on
the problem of setting back protruding ears as just one more in a long series of challenges.
He also devised new methods of tying sutures, diagnosing skull fractures and removing
diseased gallbladders.


THE AGING FACE


People do want to stay” forever young” and from the 1920′ s onwards surgeons have worked
hard to correct the difficulties of an aging face. Charles Conrad Miller (1880-1950), Chicago,
is the man credited with making the first attempt at eliminating signs of facial aging. In
1906, he described removing lax folds of skin from the upper and lower eyelids. At first he
cut away only the skin, he didn’t remove the bulging fat from around the eyeball that is

HISTORY OF FACIAL PLASTIC SURGERY


standard procedure today. To correct the deep lines along
the side of the mouth, Miller tried to burrow under the
surface of the skin and cut muscles he believed to be the
cause of the trouble. Miller blamed women for the unwanted
creases, saying that they used these muscles improperly. He
wrote the first book on cosmetic surgery “The Correction of
Featural Imperfections”. By today’s standards Millers
techniques for smoothing facial wrinkles were unsafe and
unsavoury. In the 1920 edition of his book, Miller described
some refinements to his facelifting technique. He
recommended placing incisions unobtrusively, keeping them
RHINOPLASTY : M.B. BIZRAH
Charles Conrad Miller
within the hairline while snipping and tucking to smooth the forehead. He recommended
removing the skin and fat bulge through a long horizontal incision just under the chin for
a double chin. Miller also advised surgeons to inform their patients of what to expect and
to use fine suture material and fine technique.


Frederich Strange Kolle (1871-1929), suggested a remedy for the problems of loose,
wrinkled skin on the upper and lower eyelids. His solution – removing large crescents of
the skin from both upper and lower lids – was fated to cause ectropion, ccntraction of the
skin of the lower lids severe enough to show too much of the whites of the eyes and give
the unfortunate patient a permanent, round-eyed stare.


Suzanne Noel
Suzanne Noel (1878-1954), Paris, was the first woman to devote
her practice exclusively to aesthetic surgery. In 1926, she
published “La Chirurgie Esthetique: Son Role Social”, a book
describing her ideas on the psychological impact of cosmetic
surgery, as well as offering detailed explanations of her advanced
surgical techniques. Noel believed that tugging on the skin alone
was insufficient to achieve lasting results; lifting the skin off the
underlying structures, then redraping it, provided a better effect.


Reputable surgeons described other procedures, such as
removing patches of the skin at the hairline and at the fold where
the ear joins the face to smooth an aging face. Eugene Hollander (1867-1932), claimed he
“lifted” the face of a polish aristocrat. Raymond Passot (1886-1933), France, carried out a
similar operation. He predicted that cosmetic surgery would be viewed as reconstructive
surgery had been in the past and that it would be accepted with enthusiasm by both the


RHINOPLASTY : M.B. BIZRAH HISTORY OF FACIAL PLASTIC SURGERY
public and the medical profession. Albert Bettman (1883-
1964), Oregon, U.S.A., presented the first before and after
photos in 1919. His incisions in front of and behind the ear
were closed with fine silk wire and horse hair and were
almost identical to the standard incisions of today. Next
Jacques Joseph published a photograph which showed his
preoperative and postoperative results on a patient.
In the early days, the public were very gullible and believed
in surgery that promised total rejuvenation. Charles-Eduard Serge Voronoff
Brown-Seguard (1819-1894), France, decided that injecting an extract from dog testicles
into an aging man could restore feelings and appearance of youth. Serge V oronoff (1866-
1951), Russian, living in France, felt that he could achieve better results by transplanting
entire testicles into the bodies of aging men. He felt that human organs would be best,
but as it was difficult to get donors, young monkeys were used instead. Irradiating ovaries
was the process used to attempt rejuvenation in women.
The idea of irradiating ovaries and transplanting testicles was discredited but for a while
these procedures had kept both public and surgeons hopeful of rejuvenation.


MOVING INTO FACIAL PLASTICS


An ENT, head and neck surgeon who is familiar with parotid surgery, should not find a
facelift difficult. Also, one who has practised osteoplastic frontal flap operations would
find forehead lifting a relatively easy task. Therefore, it is a natural progression for
otolaryngologists, once they have mastered rhinoplasty to move on to other parts of the
face.


Ira Tresley, MD, President, American Academy of Facial Plastic and Reconstructive
Surgery, 1969-1970, one of the best rhinoplastic surgeons. Otolaryngologists met with a
lot of opposition as they tried out their new procedures. Many of them had their privileges
from the hospital removed and suffered outright ostracism from the medical community.
Jack Anderson scheduled his first rhinoplasties as submucous resections because a good
friend and famous plastic surgeon called Neil Owens worked at his hospital. He knew
that his friendship with Owens would be threatened if he put his procedure down as a
rhinoplasty. Once the nature of Anderson’s work was discovered however, Owens never
spoke to Anderson again and their friendship was lost.


HISTORY OF FACIAL PLASTIC SURGERY RHINOPLASTY : M.B. BIZRAH

Trent Smith, had a booming ENT practice before he decided to concentrate on facial
plastic surgery. When he began doing facelifts he hired a young general plastic surgeon,
who had just finished his residency to help him. Smith also met with a lot of opposition
to his work. Morey Parkes was faced with a lot of resistance when he went on to do
blepharoplastics and facelifts. He had no one to teach him and blepharoplastics was the
hardest area to break into. Parkes commented that the move into facelifts and other
cosmetic procedures was very gradual and sporadic. Anderson and Jesse Fuchs were
doing it, other surgeons watched and learned from them, but it was a very gradual
procedure.


Oscar Becker, Chicago, was a very accomplished plastic surgeon who was willing to
allow others to come and watch his operations. One of his students was Sidney Feuerstein
who often flew overnight to arrive at Weiss Memorial at six or seven thirty in the morning
to watch Becker work and then listen to them discuss the procedure.
John Conley, head and neck cancer surgeon, was one of the first reputable surgeons to
perform facelift surgery.


In the early days, surgeons did not have access to the kinds of seminars and courses that
are available today. Despite this they were just as diligent in making the time to share
their knowledge and hone their techniques.


Beekhuis explained that he had never done a facelift during his residency. To learn about
facelifts he read and studied books about the subject, watched other surgeons performing
the procedure, spoke to and questioned people about it and saw their results. Beekhuis
found that the development of his skills in facelifts was not difficult, as he had already
been working in the head and neck region.


Nowadays, aesthetic facial procedures are practised by many specialists, including
otolaryngologist, plastic surgeon, ophthalmologist, dermatologist and maxillo-facial
surgeon. It is widely felt that the practice of facial plastic surgery by these varied
communities, despite diverse experience and training, have very much attributed to the
advances of the surgical techniques and upgraded the expertise and skills in facial plastic
surgery.


RHINOPLASTY: M.B. BIZRAH HISTORY OF FACIAL PLASTIC SURGERY


References
History of Facial Plastic Surgery


1. Aufricht G: The development of plastic surgery 12. Davis JE and Hernandez HA: History of
in the United States, Plast Reconstr Surg 1:3, aesthetic surgery of the ear, Aesthetic Plast
1942. Surg 2:75, 1978.
2. Weir RF: On restoring sunken noses, NYMJ 13. Lavater JC: Essays on physiognomy (translated
56:443, 1892. by T Holcraft), London, 1789, J Murray.
3. Roe JO: The correction of angular deformities 14. Ely ET: An operation for prominence of the
of the nose by a subcutaneous operation, Med auricles, Arch Otol 10:97, 1881.
Rec 40:57, 1891.
15. Rogers BO: A medical “first”: Ely’s operation
4. Joseph J: Operative reduction of the size of the to correct protruding ears, Aesthetic Plast Surg
nose (translated by G Aufricht). In McDowell 11:71, 1987.
F, editor: The source book of plastic surgery,
Baltimore, 1977, Williams & Wilkins. 16. Rogers BO: Commentary on “A new operation
for prominent ears based on the anatomy of the
5. Joseph J: Nasal reductions (translated by F deformity” by WH Luckett, Plast Reconstr
McDowell), Deutsch Med Wchnschr 30:1095, Surg 43:83, 1969.
1904. In McDowell F, editor: The source book
of plastic surgery, Baltimore, 1977, Williams 17. Mulliken JB: Biographical sketch of Charles
&Wilkins. Conrad Miller, “featural surgeon,” Plast
Reconstr Surg 59:175, 1977.
6. Natvig P: Some aspects of the character and
personality of Jacques Joseph, Plast Reconstr 18. Robbins HM: First is cosmetic surgery, Am J
Surg 47:452, 1971. Cosm Surg 1:47, 1984.
7. Safian J: Personal recollections of Professor 19. Miller CC: Cosmetic surgery: The correction
Jacques Joseph, Plast Reconstr Surg 46:175, of featural imperfections, Chicago, 1908, Oak.
1970.
20. Rogers BO: A brief history of cosmetic surgery,
8. Safian J: Failures in rhinoplastic surgery; causes Surg Clin North Am 51:265, 1971.
and prevention, Am J Surg 50:274, 1940.
21. Simon R: Coming of age and thieme, 1989.
9. Safian J: Deceptive concepts of rhinoplasty,
Plast Reconstr Surg 18:127, 1956. 22. Romm, Sharon: The changing face of beauty,
Mosby, 1992.
10. Goldwyn RM: Johann Friedrich Dieffenbach
(1798-1847), Plast Reconstr Surg42:19, 1968.
11. McDowell E: History of rhinoplasty, Aesth
Plast Surg 1:321, 1978.

Author

Dr Bashar Bizrah, MD, FRCS