Aesth. Plast. Surg. 11:157-161, 1987

Aesthetic _ Plastic Surgery 9 1987 Springer-Vedag New York Inc.

An Old Story: An Ivory Nasal Implant Benito Vilar-Sancho, M.D. Madrid, Spain

Abstract. The author describes the 45-year-old successful survival of a series of ivory implants, used by his father, Dr. Rafael Vilar-Sancho, to repair and reconstruct a severe nasal deformity. Key words: Nasal reconstruction - - Ivory implants

This is an old story. The majority of those who read it, including myself, had either not been born or were in kindergarten when it all began. My friend, Mr. L.J.C., was born in 1910 in Valencia, Spain, fourteen years before I was. He was a playful and mischievous child who loved to run, play, and climb trees. One day, when he was 9 years old, he was playing football (soccer) and was hit in the nose. His nose bled for a while but since he was a very brave boy, he paid no attention to it. T h a t evening, he began to notice that he was having trouble breathing through his nose, but said nothing. As the days went by, he found it increasingly difficult to breath, and his nose had swelled. His parents took him to see Dr. Rafael Vilar Ridaura, O . R . L . (Fig. 1) my grandfather, who diagnosed the child's problem as being an abscess of the nasal septum due to an infected h e m a t o m a . In his office, he applied a local anesthetic and drained the abscess; bad-smelling pus began to flow out. He packed the nose with an iodoform gauze. A few days later, the boy was fine. My grandfather, a scholarly man and the son and the grandson of surgeons, diagnosed that the b o y ' s nose would not grow properly and that it would be out of proportion with his face, " b u t that is not very important for a man!"

Address reprint requests to Benito Vilar-Sancho, M.D., c/Zurbaram no. 7, Madrid 4, Spain

H o w e v e r , it w a s i m p o r t a n t / In the questioning and ever-alert mind of Dr. Rafael Vilar-Sancho (Fig. 2) (my father), who was assisting his father in the practice at that time, he asked himself, "Will the nose of this child look like that when he grows up? (Fig. 3)" He had just c o m e back from Madrid, where he had completed his doctorate and presented his thesis. H e had been sent there by his father to finish his studies under the great Spanish masters of otorhinolaryngology, Garcia Tapia, Hinojar, and Botella. In 1914 he saw these doctors correct a " s a d d l e - n o s e " with bone grafts taken from the patient's tibia. During his earlier studies, he had already been in Berlin where, with his good French and struggling along with G e r m a n , he spent a few months in the " C h a r i t e " Hospital. H e c a m e back from Berlin quite enthusiastic a b o u t w h a t he had observed. Dr. Vilar-Sancho spent some time in Berlin before returning to Madrid. H e saw that out of the surgery p e r f o r m e d during the war came new figures to stand by the old masters; new figures with new ideas or those who had successfully applied already known techniques that had not been widely used. A m o n g these figures was Professor Joseph who popularized endonasal rhinoplasty. N e w s of this surgery reached Valencia. My father returned to the " S a n a t o r i u m Billows t r a s s e " in Berlin in 1922, where Professor Jacques Joseph, who required those who wished to assist in his operations to p a y in "gold m a r k s " (Fig. 4), 1 had In a talk by Dr. Gustave Aufricht before the Spanish Society of Plastic Reconstructive and Aesthetic Surgery during the National Congress held in Las Palmas de Gran Canaria in 1976, I commented about this. "Gusti," with his typically wonderful sense of humor, said to me, "Benito, that was the best investment of my life (Fig. 5)."

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Fig. 1. Bronze bust of Dr. Rafael Vilar Ridaura, 1900

Ivory Nasal Implant

Fig. 2. Dr. Rafael Vilar-Sancho, 1919

Fig. 3. Photograph of an Italian satiric etching with bizarre nasal shapes from the 18th century. (From the author's private collection)

B. Vilar-Sancho

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Fig. 4. Postcard sent to Dr. Rafael Vilar-Sancho on behalf of Prof. J. Joseph, inviting him to an operating session; the gold marks are not mentioned

Fig. 5. Dr. Gustav Aufricht discussing his stay in Berlin with Prof. J. Joseph with the author at Las Palmas de Gran Canaria in 1976

his practice. There my father learned the technique of endonasal ivory implants. He brought the technique back to Valencia along with Baroness Elisabeth Von Gltimer (Fig. 6), a Prussian aristocrat who had lost her husband and fortune during World War I and who would teach his children the " i m p o s sible" G e r m a n language. Of the two children, the older was two years old, and I, the third child, had not yet been born. Both acquisitions turned out well. Dr. Rafael

Fig. 6. Baroness Elisabeth Von Glfimer, 1917

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Ivory Nasal Implant

Fig. 7 (A, B) Pre- and postoperative photographs of patient with a "saddlenose" corrected with an ivory implant by Dr. Rafael Vilar-Sancho

Fig. 8 (A, B) Front and profile view of the patient, 45 years after the last ivory implant. (C) Recent radiograph of the patient clearly showing the implant which has neither degenerated nor been absorbed

Vilar-Sancho modified Professor Joseph's technique and obtained excellent results (Fig. 7), which he presented before the First Congress of the Spanish-American Otorhinolaryngology Association. During this time, his four children with the help of their "Tante Gltimer," learned to speak and to argue in correct German. In 1926, L.J.C. now a teenager whose parents, alarmed by the already known fact that his nose was not growing, took him to see my father, now a famous otorhinolaryngologist in his home town of Valencia. He recommended an ivory implant slightly larger than called for. The implant was carried out under local anesthesia; the implant had been shaped, polished, and tested on a plaster mask before being put into place. The young man once again had a nose. Some years went by and his nose was

still fine. He played sports, including football (soccer), hockey, etc., and received blows to his nose without any problem; it was just somewhat too small. He went back to Dr. Vilar-Sancho and had another operation to implant a larger endonasal piece of ivory. Years passed and the young man became an engineer and a sport enthusiast served as a regular on the Valencia Field Hockey Team, fought in the Spanish Civil War in 1936, and when peace was declared in Spain in 1939, he married. In 1941 he was still of the opinion that his nose was too small and returned to my father. A new larger ivory piece that the patient helped to design based on x-rays and his knowledge of engineering was implanted. He took up underwater fishing, which required him to wear a mask that rested directly on the bridge of

B. Vflar-Sancho

the nose. It was in the practice of this sport that our friendship began. My father used to tell me: " J u s t wait and see, one day h e ' s going to c o m e and see me with the piece of ivory in his hand and ask me to put it back in p l a c e . " But nothing happened. The ivory withstood the stress. T o d a y my friend is retired and plays golf, 45 years after his last implant and 60 years after the first one. Not long ago L.J.C. c a m e to my office to have a large lipoma r e m o v e d from his back since it has

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bothered his golf swing. I took advantage of that occasion to ask him to let me have a photograph of him and an x-ray of his nose (Fig. 8) so that I could tell this story. I thought it might serve as a lesson to m a n y who underrate what was done by the old masters like m y father and m a n y others who, without synthetic materials or antibiotics, were able to achieve results that were at least as good as our best ones today and were, without a doubt, "quite lasting."