The history of modern facial plastic surgery began more than one hundred years ago, when a few men independently began to explore a new surgical frontier of reconstructive and functional repairs that also improved appearance. As one might expect, they had trained in different specialties, including otolaryngology, and so brought to the work somewhat different knowledge and skills. By observing one another – there were few formal training programs at the time – these surgeons rapidly improved and expanded the procedures each could perform.
One surgeon in particular stands out from this time. Jacques Joseph (1865-1934) was born Jakob Lewin Joseph, second son of Rabbi Israel Joseph, in Koningsberg, Prussia. By 1892, he was working as the assistant to orthopedic surgeon Professor Dr. Julius Wolff in Berlin, Germany, when he became interested in facial plastic surgery. Joseph’s first case was a young boy, who refused to attend school because he suffered such ridicule from classmates for his large, protruding ears. In 1896, the boy’s mother approached Joseph for advice, asking if there might be surgical relief for her son’s affliction. Although Joseph was unaware of such surgery having been performed before, he felt it was possible and after careful planning operated successfully. His achievement brought him early renown when he reported it to the Berlin Medical Society; however, it also cost him his job with Wolff, who felt that Joseph had risked the reputation of Wolff’s clinic by performing the maverick procedure.
Early otolaryngologist John Orlando Roe (right) performed the first intranasal rhinoplasty in 1887. However, it is Jacques Joseph (above) whose monumental contributions to facial plastic surgery earned him a place in history as the father of the modern subspecialty. “Everyone in the beginning used some modification of Joseph’s original ideas and then changed them,” recalled John J. Conley (below). Conley’s own reputation as the foremost head and neck cancer surgeon in the world lent tremendous stature to the young AAFPRS, which he served as president in 1966. In 1974, he led the AAOO. (Photos reprinted with permission from the Educational Foundation of the American Society of Plastic and Reconstructive Surgery, W. B. Saunders Company, and Richard T. Farrior).
Two years later, Joseph performed his second facial plastic procedure on a 28-year-old man whose extremely large nose caused him such embarrassment that he could not bear to appear in public. The man had heard about the ear reduction Joseph had performed and wondered if he might also be able to reduce the size of a nose. Joseph felt this too was possible, but it was sufficiently complicated that he should practice first on a cadaver, which he did. Again he succeeded, and in May 1898 reported this achievement to the Berlin Medical Society.
Joseph’s report included a theory that Joseph had been developing, which postulated that the psychological aspect of aesthetic surgery was as important as its physical success. According to the theory, a person whose looks caused social or economic disadvantage was as severely afflicted as a person who suffered from a debilitating disease. This was a courageous and compassionate view in light of its being outside the mainstream of medicine, whose “serious” surgeons scorned the use of their skills for cosmetic purposes. It was also contrary to Joseph’s Prussian background, which sternly admonished one to make do with what life dealt. Joseph called the desire to look normal “anti-dysplasia,” not vanity.
In this 1922 photograph (lft), taken in the office of Professor Friedrich Kopsch in the Anatomical Institute in Berlin, Joseph (seated, at far left) poses with surgeons who came to study his facial plastic techniques. Left to right, seated: Joseph, Kopsch, and an unknown Spanish surgeon. Standing: Jacques Maliniac, Gustave Aufricht, and Zoltan Nagel. Aufricht and another Joseph trainee, Joseph Safian, brought Joseph’s rhinoplasty techniques to the New York area in the thirties. (Photo reprinted with permission from W. B. Saunders)
With his early success and his compassionate views, patients soon flocked to Joseph. Other surgeons also came to watch and learn. Before long, Joseph was widely reputed to be the premier facial plastic surgeon in Europe. His work ultimately earned him a place in history as the father of modern facial plastic surgery.
Meanwhile, other surgeons already had begun to explore the same territory. In 1845, another German, Johann Friedrich Dieffenbach (1792-1847) published a paper that described a procedure for nose reduction using external incisions very similar to those used by Joseph in 1898. In 1881, an otolaryngologist, Edward Talbott Ely, had performed the first correction of protruding ears on a 12-year-old boy at the Manhattan Eye, Ear and Throat Hospital in New York (he corrected one ear at a time, with a six-week interval). Robert F. Weir (1838-1927), a renowned professor of surgery at the College of Physicians and Surgeons in New York City, claimed to have performed a four-stage rhinomiosis totalis (total nose reduction) in 1885. A fourth surgeon, John Orlando Roe (1848-1915) is credited with performing the first intranasal rhinoplasty in 1887. Roe, who practiced in Rochester, New York, was an otolaryngologist by training, and he had published more than thirty papers on various otolaryngologic subjects before his historic rhinoplasty. Four years later he made history again, when he published an article describing the endonasal hump removal in five patients, as well as the use of a spring wire for internal splinting of the nose.
Samuel Foman (below) went to Europe to study with Joseph in the thirties, then organized a course around Joseph’s methods. Among the seven hundred fifty otolaryngologists he taught were two Maurice H. Cottle (below) and Irving B. Goldman (below) who went on to develop their own courses.
Nonetheless, it was Joseph who became world famous. During World War I, he served as director of the Division of Facial Plastic Surgery of the Charity Hospital in Berlin.
Under emergency conditions, he restored the war-ravaged faces of innumerable German soldiers. He studied and classified their deformities, later writing many papers and his monumental book, Rhinoplasty and Other Facial Plastic Surgery, wherein he first recorded his theory that anti-dysplasia was a treatable disease.