The History of Rhinoplasty ⑫ — What has not changed in 3,600 years

Once I started writing, it ran long and there was too much to say, and it came to twelve parts in the end.

We began at a papyrus from 1650 BC and have arrived at my consulting room.

The question that remains at the last is this. Over 3,600 years, what has changed and what has not?

Let me think for a moment about what changed

Very nearly everything.

Anaesthesia arrived. That is the biggest one. Sushruta’s patients and Tagliacozzi’s patients were operated on awake. How long pain could be borne was the limit on how long surgery could take.

We handle infection rather better. In an age without antisepsis or antibiotics, whether an operation succeeded was in large part luck.

Instruments became finer, suture materials improved, and we can look at a CT scan. Above all, records accumulated.

One person’s experience no longer disappears with that person but passes to the next generation. It is thanks to that this series was possible at all.

Let me also consider whether anything has not changed

Three things remain.

First, the body still pushes out what is not its own.

I said this in part nine.

After a century of testing every kind of material we came back, in large part, to a person’s own tissue. That is not a limit of technique but a condition of the body. I do not think it will change much from here either.

Second, to get something back, part of the tissue somewhere has to be given up.

I mentioned this in part ten. Sushruta used the forehead, Tagliacozzi the arm, Gillies the chest. Even now, to use rib cartilage you open the chest. To use ear cartilage the shape of the ear changes. Thousands of years on, it is the same.

And one more — which may be the most important of all

There is something that outlasts these.

A person stands in front of the world with their face.

The reason someone whose nose was cut off in ancient India was excluded from society, the reason a collapsed bridge became a mark in nineteenth-century Europe, the reason the shape of a nose was treated as identity in twentieth-century Berlin,

and the reason someone in Korea today is hurt by a remark about how they come across — they are all the same.

Asked whether that is unjust, I honestly think it is a little unjust. As I have written before.

But I also know the injustice is not going to disappear tomorrow. And that someone caught in the middle of it will be coming to see me today as well.

Some fields of medicine cure disease. Rhinoplasty is a little different. Much of the time it deals with what is not a disease.

So I think this work calls for a different kind of judgement. Not only what can be done, but what will not be done, has to be decided alongside it.

I said in part one that the Edwin Smith Papyrus sorted each case into “one I will treat,” “one I will contend with,” and “one not to be treated.”

A physician 3,600 years ago had that last category. To hold not only a list of what can be done but a list of what should not be — I think that is an old condition of this profession.

If I judge that surgery is unnecessary, I say so. If I judge that waiting is better, saying so is the right thing to do.

Not because it is some grand conviction, but because if I lost the ability to say it, I would no longer be able to explain what it is I do.

Finally

Nose surgery did not set out from beauty.

It was the work of letting someone breathe, of returning what had been lost, and of letting a person stand in front of others with confidence.

These days I mostly operate for aesthetic reasons. But following this line down, I always arrive at the same place.

The work of bringing someone closer to what they originally had — or to what they might originally have had.

A piece I opened a notepad to start because I was asked to write something about my philosophy has run this long, and going back through sources and literature I had only ever found interesting,

what I confirmed again is this. In 3,600 years the tools have changed entirely, but the character of this work has not changed much.

I do not think it will change much from here either.

Thank you for reading.

Ref. The references for this series are at the end of each part.