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This is a slightly different story about nose surgery. It does not begin in an operating room, and it does not begin with people wanting to look more beautiful. It begins with the opposite: an attempt to disfigure. Around three thousand years ago, in some parts of the world, cutting off someone’s nose was one of the harshest punishments.
Imagine a sentence that never ends: every conversation, every walk in the street, every look in the mirror. Some of the earliest plastic surgery in history appears precisely in the effort to rebuild these people’s faces.
Ancient Egypt: repair before beauty
The earliest written traces of nasal surgery come from ancient Egypt. The Edwin Smith Papyrus, with knowledge reaching back to around 3000–2500 BC, describes facial injuries, broken noses and how to manage them. This is not aesthetics; the problem is basic. The nose is broken and displaced. How can we bring it closer to its original state? It is still the first question a surgeon asks today: what is damaged, what can I correct, what must I protect?
Sushruta and a leaf
In ancient India, where nose amputation was used as a visible, stigmatising punishment, the need for reconstruction grew. Here we meet one of the most famous names in surgical history: Sushruta, thought to have lived around 2,500–3,000 years ago. The Sushruta Samhita contains a remarkable description of nasal reconstruction.
Today we measure a defect with photographs and software. Then, they used a leaf. The leaf was placed over the missing area to define its shape, and a piece of skin was prepared from the cheek. Crucially, the skin was not cut free: one side stayed attached to keep its blood supply.
A small correction to a common story: Sushruta is often said to have used forehead skin. The classic early description is closer to a cheek flap; the forehead flap now known as the “Indian method” developed later. The principle was so good that the forehead flap is still a valuable technique for large nasal defects today.
Italy: stitching the arm to the nose
In 15th-century Italy, surgical families such as the Brancas worked on nasal reconstruction. Taking skin from the face left scars at the donor site, so Antonio Branca is said to have taken it from the arm instead. The skin stayed attached to the arm and was stitched to the nose, so the patient lived for a while with the arm fixed beside the head, until the new tissue took and the connection was cut. It looks like a torture device, but the surgical principle is sound and still used today.
In 1597, Gaspare Tagliacozzi of Bologna systematised the method in “De Curtorum Chirurgia per Insitionem”, one of the first comprehensive books devoted to plastic surgery. Patients sometimes ask me whether the splint really needs to stay for a week. If I hung a few of Tagliacozzi’s drawings in my clinic, I suspect the complaints would stop.
From India to London
In the 1790s, a man named Cowasjee, whose nose had been cut off as a prisoner of war, was treated in India with a forehead flap kept attached between the eyebrows. The operation was published in London’s Gentleman’s Magazine in 1794 and read by Joseph Constantine Carpue, who performed a successful forehead-flap reconstruction in England in 1814 — reportedly in about 15 minutes, which sounds quick until you remember there was no modern anaesthesia.
A new question: can we change a nose that exists?
For about 2,500 years the question had been “how do we build a missing nose?” At the end of the 19th century it changed. In 1887, American ENT surgeon John Orlando Roe published an aesthetic nose operation performed from inside the nose, without external incisions, and is often called the father of aesthetic rhinoplasty. In Berlin, Jacques Joseph recognised that being physically healthy does not mean being free of distress about one’s appearance, published his rhinoplasty techniques in 1898 and designed instruments still used today, alongside modern piezo devices.
War, reconstruction and modern rhinoplasty
The First World War produced severe facial injuries on an unprecedented scale. Harold Gillies, whose early training was in ENT, was among the surgeons who advanced flaps, grafts and the use of cartilage and bone. Modern rhinoplasty is, in part, the meeting of these two worlds: reconstruction and aesthetics.
From “remove the excess” to “what should I preserve?”
For much of the 20th century, rhinoplasty was mainly a reduction operation. Over time it became clear that not every structure is excess: some support the nose, some keep the airway open. Removing too much cartilage can make a nose that looks good in the first year lose support years later; narrowing too much can harm breathing. Preservation rhinoplasty, popular today, revives ideas first described over a century ago — yet there is still no single best technique for every nose; the method is chosen for each anatomy.
What has really changed in 3,000 years?
Sushruta had a leaf; today we discuss how one or two millimetres change a face. The technology is incomparable, but some questions in the surgeon’s mind are the same: how do I preserve blood supply, what can I remove and what must I leave, will this nose breathe well — and will it truly look like it belongs to this person’s face?
The history of rhinoplasty is not really a history of beauty. It begins with the effort to give back what was taken from someone’s face, and arrives, three thousand years later, at the question: what is the right nose for this person?
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