Rhinoplasty in China: A review of the most important events in its history of development

Shengli Li,Qingfeng Li

Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China

Keywords:Rhinoplasty History Costal cartilage Society Congress

ABSTRACT A review of the literature in commonly used retrieval systems generally yields minimal or no pertinent information on the early works of Chinese doctors.Herein,the early works in rhinoplasty by pioneers Dr.Maolian Hu(胡懋廉) and Dr.PC Nyi (倪葆春) were retrieved from the database of Chinese Medical Journal published before 1949 that overseas doctors could not gain access to online possibly due to the language barrier in collecting and processing those old professional data by main retrieval systyems.They published original articles on costal cartilage applications for correction of saddle noses in as early as 1939 and 1949,respectively,which represent the earliest attempts of treating nasal deformities with costal cartilages in China as well as in Asia.The private cosmetic surgical practices in rhinoplasty from the 1930s to the 1940s were recovered and briefly reviewed,and some of the most important clinical cases were presented.Other important events related to rhinoplasty,such as the establishment of the first national society of rhinoplasty in Chengdu,China in 2011 and the successful performance of the first national congress on rhinoplasty in Shanghai,China in 2012,were included.

1.Introduction

As the economy grows and the standard of living rises,people naturally demand for a better quality of life.The popularity of cosmetic surgery in China has been fueled further by a wide range of social media coverage and the advancements in communication tools.These have contributed to a large number of people seeking plastic surgical procedures,including rhinoplasty.It is well known that the human nose has a pivotal role in facial beauty,which is probably why rhinoplasty is one of the earliest surgical procedures conducted by Chinese surgeons,dating back as early as the 1930s-1940s when China was still a poor and underdeveloped country.However,a review of the literature in commonly used retrieval systems yields minimal or no pertinent information on the early works of Chinese doctors no matter what language they were published in domestic journals,possibly becasue of the language barrier and difficulty in collecting and processing those old professional data by main retrieval systems.Accordingly,we aimed to summarize and report some of the most influential figures and important events related to rhinoplasty based on our knowledges and experiences in the development of this field to date.

2.Early forgotten works in rhinoplasty by the pioneers

The first case using a piece of rib cartilage containing a perichondrium was reported in a patient with a saddle nose resulting from septal abscess by Dr.Maolian Hu.He performed the surgery in October 30,1936 and published the results in 1939 in the Chinese language in theChinese Medical Journal.1Dr.Hu described the entire process of the patient’s treatment in detail from the beginning of the diagnosis of abscess in the septum to the surgical drainage of the pus and the resultant deformity of the saddle nose.Most importantly,he corrected the saddle nose 5 months later after the first surgery by transplanting a piece of rib cartilage graft.The rib cartilage graft was harvested from the conjoining site of the seventh and eighth ribs;it had a width of 1 cm and a length of 8 cm with an intact perichondrium.However,its thickness was not described in the report.He inserted the rib cartilage graft into the subcutaneous pocket of the nose through a vertical incision in the columella.He specified that the piece of rib cartilage graft obtained was too thin and easily bent during the surgery,yet still yielded a remarkable improvement in the appearance of the nose after 3.5-month follow-up postoperatively.The schematic demonstration of his method is shown in Fig.1.To our knowledge,the report represents the earliest attempt in rhinoplasty in China,which is the first article on rhinoplasty in China and could also possibly be the first one in Asia.

Fig. 1.Schematic outline of the incision of the columella and placement of a piece of rib cartilage graft.

Fig. 2.Screenshot of the title of the article by Dr.PC Nyi in the Chinese Medical Journal in 1949.

Fig. 3.Preoperative (above,frontal and lateral views) and 6-month postoperative (below,frontal and lateral views) images of a female patient with a saddle nose corrected with costal cartilage application in the article by Dr.PC Nyi in the Chinese Medical Journal in 1949.

Dr.PC Nyi is another genius surgeon who also pioneered rhinoplasty in China.He set up the first plastic surgery clinic in China in 1928 in Shanghai St.John’s University (from 1879 to 1949).He is widely recognized as a pioneer in plastic surgery in China after having graduated from the Johns Hopkins University,USA.His article entitled“Correction of the saddle nose by transplantation of costal cartilage”was published in English in theChinese Medical Journalin 1949.2Unfortunately,it has been overlooked for several decades in the field of plastic surgery because of its inaccessibility in most frequently used retrieval systems,such as PubMed,even though it was written originally in English.

Since few reviews have investigated the history of rhinoplasty in China,it is worthwhile to include the most distinguished highlights of the article by Dr.Nyi.He reported that the use of a costal cartilage for the correction of a saddle nose was not new;Von Mangoldt described the surgical method in 1899.His description of the history of costal cartilage application remains a strong reminder for the surgeons of the present generation that harvesting a rib cartilage for correcting nasal deformities in rhinoplasty is nothing new,entirely contrary to the entrenched belief among some doctors who had thought otherwise.Dr.Nyi reported the case of a woman with a saddle nose resulting from an injury 13 years previously,who was admitted to the Margaret Williamson Hospital in Shanghai on November 19,1948.Aside from nasal disfigurement,the patient also had a difficulty in respiration through the nose and an abnormal nasal tone to her speech.The surgery was performed under general anesthesia,which is currently accepted as the standard method for this kind of rhinoplasty.A piece of costal cartilage measuring 6 cm in length,0.7 cm in width,and 0.4 cm in thickness was harvested,almost similar to current methods.A costal cartilage is usually indicated nowadays when a large amount of graft and strong support are needed in the reestablishment of the nasal structure.His method is considered excellent in terms of the anesthesia and costal cartilage excision procedures.The most intriguing part of his surgical skills lied on his meticulous carving of the costal cartilage graft,in which a notch was created in the piece of cartilage 1.5 cm from one end,and the perichondrium was left intact.Thus,the cartilage was angulated at the notch to form an inclined“∠”.The“∠”cartilage graft acted as a frame to hold up the nose as well as to fill in the subcutaneous pocket caudally to support the nasal columella simultaneously.It was emphasized in the case report that the female patient was especially satisfied with the improvement of her nasal breathing and clearance of her speech,which could prove to be an early example of improvement of both appearance and function in rhinoplasty.

The reports by Dr.Hu and Dr.Nyi on the application of costal cartilages and this review could possibly rewrite the history of rhinoplasty in Asia,as a rib cartilage had previously been thought to be used first by Naria in 19653and Ota in 1969.4Naria and Ota reported their own works regarding costal cartilage application in the nose inKeisei Gekain Japanese.However,the full details of these reports remain elusive,because their abstracts are not available in PubMed.Nevertheless,based on the titles,the first article reported unsatisfactory results,while the second article reported two cases of saddle noses treated with an autologous fresh costal cartilage.These aforementioned reports together represent the earliest attempts of treating nasal deformities with costal cartilages in Asia.Since the articles by Dr.Hu and Dr.Nyi published in theChinese Medical Journalin 1939 and 1949,respectively,are not available in the vast majority of global libraries,a screenshot of the title and the patient’s photos in the original report from Dr.Nyi are shown in Figs.2 and 3,respectively.

3.Private cosmetic surgical practices from the 1930s to the 1940s

Some cosmetic surgery advertisements related to augmentation rhinoplasty had been published in the newspaper“Shun Pao”(established in 1872)by private doctors in Shanghai.

Herein,some of the neglected facts of private cosmetic surgical procedures for rhinoplasty in the early 1940s were reviewed.Dr.Chongming Shi has preserved invaluable pictures of the clinical works of his father,the late Dr.Guanghai Shi.The senior Dr.Shi began to run his own clinic in Shanghai and other cities in the 1940s after he graduated from Showa University in Japan.After his return to China in 1941,a number of cosmetic surgical procedures were performed,including rhinoplasty,which yielded extremely satisfactory results even evaluated by the current beauty standards (Figs.4 and 5).He became the chief of the Department of Dermatology in the former Shanghai Tenth People’s Hospital (currently called Shuguang Hospital) in 1956.Notably,the junior Dr.Shi was a staff in the Department of Plastic and Reconstructive Surgery in Shanghai Ninth People’s Hospital,who had studied at the Shanghai Second Medical College from 1978 to 1991 to obtain a master’s degree in plastic surgery under the tutorship of our mentor,Prof.Ti-Sheng Chang,who founded our department in 1961.This represents an interesting anecdote in the history of plastic surgery,which is possibly the earliest record of a son in China following the steps of his preeminent father four decades later in the field of plastic surgery.

4.Other important events related to rhinoplasty

One of the most important events in the history of plastic surgery in China is the training course in plastic surgery held in Shanghai Zhongshan Hospital under the tutorship of Prof.Webster from the USA.5Several giants,including Prof.Ti-Sheng Chang (Shanghai),Prof.Ruyao Song (Beijing),Prof.Hongyin Zhu (Beijing),Prof.Liangneng Wang(Xi’an),and others,who played a great role in the development of plastic and reconstructive surgery in China,including rhinoplasty,attended the course.Prof.Ti-Sheng Chang published an article entitled“Correction of complicated saddle nose: report of 63 cases” in theEuropean Journal of Plastic Surgeryin 1986;therein,a lengthened nose was achieved using a mucoperiosteal flap from the nasal bones that was advanced caudally.6

Rhinoplasty has rapidly advanced after China’s reform and opening to the outside world since 1978.An increasing number of plastic surgeons and doctors from other surgical fields have demonstrated their enthusiasm and interest in rhinoplasty.The first national society of rhinoplasty(104 members) was established in Chengdu,China in 2011 (first president:Qingfeng Li,succeeded by Shengli Li and then by Qian Tan),which was affiliated to the Chinese Doctors Association.Subsequently,the first national congress specifically on rhinoplasty was successfully held in Shanghai in 2012 with more than 350 participants present,followed by eight national annual meetings until the outbreak of the COVID-19 pandemic.It was organized by Prof.QingfengLi as the congress chairman and Prof.Shengli Li as the executive chairman (Fig.6).Five years later,another national society of rhinoplasty affiliated to the China Association of Aesthetics and Plastics was formally founded in the spring of 2016 in Shenzhen(president:Dong Li;president-elect:Shengli Li).To date,it has enrolled 252 members and held national conferences on rhinoplasty annually.

Fig. 4.Correction of a severe saddle nose by Dr.Guanghai Shi in the 1940s,with no record left for the surgical method and implant.

Fig. 5.Correction of another saddle nose by Dr.Guanghai Shi in the 1940s,without any attached written descriptions.

Fig. 6.Collected papers (left) and agenda (right) of the first national congress on rhinoplasty held in Shanghai in 2012.

Rhinoplasty has long been one of the main hot topics in every plastic surgery conference in China owing to the strong public need as an emerging market in plastic surgery.Chinese doctors have contributed much more than before to international journals and congresses and have increasingly been recognized in this professional field.Chinese rhinoplasty surgeons have established a close relationship with their counterparts from Asian countries and regions as well as the USA and European countries.

5.Conclusion

This review presents a general description of how rhinoplasty in China has evolved from the 1930s to date.The remarkable articles on rhinoplasty by Dr.Maolian Hu in 1939 and Dr.PC Nyi in 1949 published in Chinese and English,respectively,in theChinese Medical Journalrepresent the early attempts of correcting a saddle nose with a costal cartilage in the field of rhinoplasty in China.They could also possibly be the earliest reports in Asia,yet they were overlooked.The national society of rhinoplasty in China plays an important role in the development and advancement of rhinoplasty nationwide.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Authors’ contributions

Li S: Conceptualization,Writing-Original draft.Li Q: Supervision,Writing-Review and editing.

Competing interests

The authors declare that they have no competing interests.

Acknowledgments

We are grateful to Dr.Antang Liu from Shanghai First People’s Hospital for his help in providing the invaluable original article of Dr.Maolian Hu.We would also like to extend our thanks to Dr.Chongming Shi and Mr.Jintai Lin from the Times Plastic Surgery Hospital in Shanghai for providing the patient photos of Dr.Guanghai Shi.