How it began
The Sushruta Samhita, a Sanskrit collection of medical writing attributed to the sage and surgeon Sushruta and dated to around 600 BCE, contains one of the earliest known references to nasal reconstruction. In ancient India the nose symbolized honor and dignity, and cutting it off was a common punishment for crimes such as adultery, which left the victim disfigured and socially ostracized. Sushruta's operation answered that need.
How it works
The text describes using a creeper leaf to measure the defect. A patch of living flesh of that size was then sliced from the cheek, left attached at one side, and rotated to cover the nose. The flap was fixed with bark fibers or horsehair sutures, and hollow tubes or reeds were placed in the nostrils to keep them open. The wound was dressed with ghee and honey. Over time a flap from the forehead replaced the cheek flap, probably because of its better blood supply and flexibility.
How it spread
Families in India, such as the Kanghiari family, passed down rhinoplasty techniques through the generations during the 14th and 15th centuries. The method was translated into Arabic and became known as the Indian method. It spread through Arabian lands and Persia and reached Sicily in the 15th century, where Branca de Branca developed the Italian method using a flap from the arm. In the 18th and 19th centuries British surgeons, including Thomas Cruso and James Findlay, observed Indian practitioners performing the forehead-flap operation.
What changed first
Joseph Carpue documented the Indian operation in 1816 in his account of two successful operations for restoring a lost nose from the skin of the forehead, performed on two officers of the British army. His book described both the Indian and the Italian methods and brought the forehead flap into European practice as a reliable method of reconstruction.
What lasted
The forehead flap remains associated with nasal reconstruction, and the technique is still called the Indian method. Sushruta's text also described skin grafts, sliding flaps and pedicle grafts for other deformities of the face and body, which the journal ENT and Audiology News describes as laying the groundwork for modern plastic surgery. The same source notes that the history of the change from cheek flap to forehead flap remains speculative.
