A (2:42)

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B (3:31)

Daniel, let's start with, like, why there was a need for fake noses in the first place. Can you tell me why people in the past might need a nose job or a new nose entirely?

C (3:42)

So my, my understanding was that if you go back millennia to India, there was an active practice of corporal punishment where let's say you slept with someone else's partner and you were an adulterer, you would get part of your nose chopped off.

B (4:00)

Really? Why?

C (4:01)

Your nose, it's very embarrassing and visible. You can't hide it easily. So it's a deterrent. And it's supposed to say, hey, don't sleep with other people's partners, otherwise you'll get part of your nose chopped off. And I think the issue is that people back then are pretty much the same as people now. So there were a lot of noseless people walking around.

B (4:22)

Wow.

C (4:23)

And then as you progress through the centuries, more and more connections to missing noses come up, especially in the context of things like dueling, where it's illegal in many cases to duel. Especially if you kill someone, it's really bad. But if you chop someone's nose off or damage their face, it's embarrassing for them. They can't hide it. This isn't just like a one off thing. Like we have all these weird accounts of this, including Tycho Brahe, the famous astronomer who lost his nose in a duel over a math proof and wound up wearing a metal nose. This is the alternative to the metal nose. And then from what I understand, additional problem popped up that was even worse, which was that we brought syphilis back from the New World as Europeans, and that has a really nasty effect where it can cause death of nasal tissue. If you look at certain anthropological accounts, it got so rampant at certain places and times that if you walked around with a damaged nose, people just, people.

B (5:26)

Assumed you had syphilis.

C (5:28)

Yeah. Yeah. And at the time, the Italians called this the French disease and today the French call this the German disease. And they just passed the ball. It goes around. No one, no one wants to acknowledge it.

B (5:40)

So the solution to all these, like nose problems was reconstructing a nose so that people don't have these ideas about you syphilis or a duel or anything like that. But the very first nose reconstruction is 2500 years ago, at least in India. Like, how did that work? And just a heads up to our squeamish listeners, you might want to fast forward past this part because it's going to get a little, maybe gross.

C (6:06)

So the Indian method was produced by someone whose name I'm going to butcher, but I think it's Sashruda. And he's considered the father of modern surgery. He's considered to have written the first textbook on it. And what they pioneered was the use of skin flaps and living skin grafts from the forehead. And you could peel forehead skin down, twist, flip, cover over the nose and use it to help integrate and restore missing parts of the nose. And I know less about the full details of that method because I haven't been able to track down a formal translation of how all of that worked. But the first time Europeans came into contact with the Indian method was in the 1800s, an issue of Gentleman's Magazine, when a member of the British Raj reported seeing an Indian worker who had had this procedure done. So that's kind of how it, that particular version was presented to the west, let's say.

B (7:04)

So how, how did this method like, change over time from, you know, using the skin graft from your forehead? Did it stay the same in Europe thousands of years later or a thousand years later?

C (7:16)

So the weirdest part of that story is that the method seems to have totally changed by the time it got to Europe. This aura of secrecy sort of popped up. And what happened was, as far as we can tell, a copy translated of the book from Cicerudon Surgery. And this method seems to have reached Sicily probably sometime in the 1400s. And that's where it somehow seems to get picked up by Heinrich von False Paint, which will lead to the paper how to make a new nose for someone when it's off entirely and the dog has eaten it.

B (7:50)

So it makes it like 2000 years later, it makes it to Europe.

C (7:54)

That's as far as I can tell. And even though the how to make a New Nose paper doesn't really get published and gets lost in the secret archives of the Teutonic knights. For about 400 years, the method is continuously practiced in Italy by two sort of dueling rhinoplasty families called the Vianos and the Brancas.

B (8:18)

Okay, got it. And you said that like Europeans changed that method and they do it differently than when it was first practiced in India.

C (8:26)

The European method for reconstruction involved taking skin from the arm rather than from the forehead. And this part may be triggering for squeamish people, but two parallel incisions along the biceps and then placing an inert biomaterial, like a oil soaked cotton cloth or something underneath that to stop the skin from healing again. And that produces what's called granulation. The skin starts to thicken and get squishy because it's trying to heal and it can't and there's an immune response. And so the skin really.

B (8:57)

Because it's still attached to your eyes.

C (8:59)

Yes, it's still fully attached. So it's hanging off like a flap. And that's super clever because the reason you do that, same as why the Indian method would keep skin attached to the forehead as you keep the blood supply there. And that's a modern technique that we call using the body as a bioreactor. You're letting the body grow itself because blood supply is one of the biggest challenges still today in this field of tissue and organ engineering. So they solve that problem by leaving the flap attached to your arm, but now they have to deal with your face. And so the connection there would be that you get the patient into the prototype of a hoodie that's got all these attachment points and straps and things on it so that you can then strap the patient's arm to their face, debride the wound on the nose so it's reactive and healing again and essentially kind of suture the skin flap around the face. And the patient will stay like that for a variable amount of time, but.

B (9:57)

Like with their arm up like they're.

C (9:59)

Holding, with their arms strapped to their face for, from what I can tell, about 40 days.

B (10:04)

40 days, that's Lent.

C (10:07)

And you've already spent a couple weeks thickening the skin on the arm already. So not a particularly gentle process. And once that's done, you snip, snip, snip him. But a bing bada bang, you got a nose again and you just got.

B (10:23)

A scar on your arm.

C (10:24)

Yeah, that was one of the methods. And as far as I can tell, that particular form was last performed and at least in the literature, in 1987, man shot his nose off with a shotgun. This paper has full photographs of his missing nose, his arms strapped to his face, and how it looks afterwards where you can't even tell. Wow. And there's numerous primary accounts of letters from patients who've had this procedure and say back in the 1500s, it is very painful, but like the results, five stars would do it again.

B (10:57)

We're talking about this and I'm realizing that like, scientists have dealt with this like, like issue of like regrowing tissue for thousands of years. But like, what do we do now?

C (11:09)

We'll do similar things to this. There are methods where we can still use skin flaps in the same kind of way. We're just much better about sterilization, pain, scarring, that sort of thing. So that's a great method. And it relies on the body to again, do some of the hardest stuff, like providing the blood supply and growing the squishy tissue and stuff. We also have all sorts of other techniques like bioprinting of soft materials and producing these scaffolds that are custom shaped to the size shape geometries of the nose that you want that kind of thing. You can grow parts of yourself inside your body. So if you have a missing chunk of bone in your jaw, there are cool examples where you can regrow part of that bone in a titanium cage implanted, say in your thigh or part of your abdomen so that it gets fully taken care of and protected by the body until it's ready and then you pop it back in the face.

B (12:06)

Yeah, I mean, like you said, you're studying bioengineering, biomaterials. You're currently working on a project that is inspired by all this history. Can you tell me more about that?

C (12:17)

So everything we've done, as far as we can tell, has been based on this model of a scaffold which provides structural support. So you can think about cells as having two ways to attach to the world around them actively. They have proteins that they use to move around and pull on things. We can call those sort of like foot proteins. Their formal name is integrins. And then they have handshake proteins, which I call handshakes because they only use them when they find another cell. It's kind of like a secret handshake where you do a bunch of different funny things with your hand. And only someone who knows that sequence, you know, gets the secret handshake. Right.

B (12:52)

This whole story is about secrets. I see this now.

C (12:56)

And so we just started thinking about if you don't go after attaching to something with your feet, could we attach to something with the cell's hands? So now we build things that are completely synthetic, but the surface that the cell encounters, it thinks is another cell and it treats it as another cell and it sticks to it using the secret handshake proteins. And the cells just think it's another really weird looking cell and they do something totally different. That you would never normally see. Wow.

B (13:25)

Okay. So you're, like, tricking these cells into thinking they're, like, connecting with these friends, these similar cells instead of a foreign material. So what's the end goal of this research?

C (13:35)

There's a couple of different directions that we're excited about. One of them is very simple to state, which is just improving how well an implant integrates with and fuses into the body to stop infections when an implant sticks through skin, or to better attach implants to soft tissues, which we're really not very good at. And. And so the flip side is, if we can make things that look like cells, maybe we can reprogram how tissues are growing. So maybe that helps us get better with things like regenerating missing tissues or better, growing organs in a lab or something like that, where we're able to reprogram things from the inside.

B (14:12)

Wow. Okay. So, Daniel, is there, like, a wider lesson in rhinoplasty history for anyone continuing the work or thinking about reconstructing tissue like yourself, or in, like, even other lines of work? Why is it so important for you to tell this story?

C (14:28)

Oh, so many answers. It's a great question. I think that the most visceral one is everyone likes this sort of story, whether you're a scientist or a non scientist. Yeah. And if you're a scientist and you hear this kind of story again, you get that sense of humility, but you also get that sense of connection. We can see that there's this very long lineage where we've been working on this for a long time. Many people have contributed to these things, and each of those contributions is important in their own way. And that you, as someone working in this field, have some hope of coming up with something new and exciting, too. But if it feels hard, it's because it is hard and something we've been doing for a while.

B (15:07)

Daniel, thank you so much for this truly fascinating history lesson. I had a great time. Thank you so much.

C (15:13)

Yeah, me too. It was fantastic to get to share this, so thank you.

B (15:21)

This episode was produced by Hannah Chin. It was edited by our showrunner, Rebecca Ramirez, and the facts were checked by Tyler Jones. Robert Rodriguez was the audio engineer. Beth Donovan is our senior director, and Colin Campbell is our senior vice president of podcasting strategy. I'm Regina Barber. Thank you so much for listening to Short Wave from npr.

A (15:48)

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