Open vs Closed Rhinoplasty

An “open” rhinoplasty involves making a small, non-linear incision in the columella of the nose- the part of the nose between the nostrils. An endonasal or “closed” rhinoplasty is all performed using incisions inside the nose. There is a significant learning curve to any rhinoplasty, but the closed approach is more difficult to learn. The open or closed approach is more than just a way to access the nose, however; certain techniques can be most optimally performed with one or the other approach while others can be well done with either. Most experienced rhinoplasty surgeons can select the best approach for your specific needs.

Open vs Closed Rhinoplasty

Problems with the nose profile or width of the bones can usually be well addressed with a closed approach. Sometimes however if there is a lot of reduction or a narrow nose “spreader grafts” are helpful to maintain the width and airway in the middle of the nose; these can be placed in a closed fashion but are most easily and precisely performed with the open approach.

Minor tip narrowing can be done with a closed approach but at least in our hands more major tip refinement and narrowing can best be done with an open approach. In more complex rhinoplasty cartilage grafts from the septum, ear, or rib may be used to support or contour the nose. There are situations where a closed approach with a “precise pocket” is the optimal way to place these grafts. There is no need in this case to suture the grafts in place and healing is faster and more predictable. Obviously, complex nose reconstructions such as the cleft lip nose are usually best done with the open approach.

Overall the closed or endonasal approach avoids the scar, is faster to perform, and heals more rapidly. We select it whenever we feel we can achieve the patient’s goals just as well as if we used the open approach. The end outcome however is most important and if we believe the open approach can achieve a better result we use it.

This is a discussion we have with the patient based on their specific goals and anatomy.

Science and Surgical Excellence

Research and surgical advances go hand in hand. We have published over 225 books and manuscripts- most to advance the art and craft of facial plastic surgery. Google Scholar provides an effortless way to keep track of publications and citations. Our profile is at – http://bit.ly/TLCSeattle. It is interesting to look at the most popular articles from our 226 citations. They are listed below but reflect the range of facial plastic surgery. Surgical Anatomy of the Face was my first major book and still my favorite. I was able to work with Kathleen Makielski, an amazing surgeon and artist, to create illustrations that clearly and beautifully demonstrated key anatomical relationships. Its popularity shows the importance of anatomy to surgeons. The second was my first major research combining my undergraduate work in mathematics and computer science with skin flap design. We used finite element analysis, an engineering technique, to examine how to best close wounds. It is an example to show why the best science is frequently found at the intersection of different disciplines. The third is one of the first papers to apply outcomes analysis to cosmetic procedures so they can be measured, and therefore our techniques improved. The fourth was an exciting study to look at gamma interferon to control poor scarring. Unfavorable scarring is probably the most important problem in plastic surgery and the study showed promise. The fifth was our clinical paper on how to treat unfavorable scarring using practical techniques. The sixth was another important anatomical study that demonstrated blood flow in the nasal tip and that the open incision didn’t significantly impact blood flow to the tip and thus was safe. The seventh was a review of our experience with 3D imaging. This is so important now in our practice with our new 3D imaging and analysis system- The Aesthetic Studio. The eighth was one of my first major papers when I was doing a lot of facial trauma and helped inform decisions on how to manage frontal sinus fractures. The ninth was my second major book, this one on facial reconstruction in which we designed algorithms to help surgeons decide which technique to use for a given defect. It has become a “go to” resource for many young surgeons. The tenth was a practical study which looked at the long-term outcomes of using demineralized bone for nasal implants. It showed these implants used to make the nose profile stronger didn’t always last well over time. Negative studies are good for patient care also!

We will keep doing good research and publishing to help our patients and improve their knowledge base of facial plastic surgery. Here are our “top ten” and a link to the rest- http://bit.ly/TLCSeattle

Global Surgical Outreach- Looking Forward to 2018

The primary mission of Global Surgical Outreach is to reduce the global burden of surgical disease through education, development of medical infrastructure, and the provision of pro bono facial reconstructive surgery both in the US and the less developed world for adults and children. We provide specialized treatment for patients who were born with cleft lip palate deformities, those who have suffered injury from war and those affected by other forms of violence including domestic violence. We believe we can best accomplish our mission by developing innovative approaches and partnering with other organizations when there is synergy.

Projects for 2018 include-

  1. Teaching a reconstructive surgery course and providing reconstructive surgery at the Black Lion Hospital in Addis Ababa, Ethiopia. This is a partnership with Seattle Anesthesia Outreach.
  2. Support the development a hospital for training in West Africa in partnership with the Foundation for Special Surgery. The hospital will be located in Accra, Ghana. Accra is a great choice as it is in a safe country with a stable government, modern infrastructure and good transportation. This surgical hospital will serve as a center where surgeons and nurses from the region can be trained while also providing highly specialized surgical care. The need for this facility is tremendous. Training surgeons locally in the region by world experts in a well-equipped facility is the way to sustainably improve healthcare delivery in Africa.

  3. Surgical hospital design by IB-Federlein Architectural design by IB-Federlein

  4. Organizing and implementing missions to Balfate, Honduras as part of the University of Washington team.
  5. Continual development of the UW Fellowship in Facial Plastic Surgery and Global Health. In addition to working on global surgical missions, the fellows will manage our blog on global health and develop a research project and publication in the area of the global burden of surgical disease.
  6. Develop a program for a twinning program between the Larrabee Center Seattle and Hangzhou China- the program of Dr. Sufan Wu. Continue the educational exchanges and mutual teaching.
  7. Provide more information to facilitate access to our program of pro-bono surgery for the victims of domestic violence.

www.GlobalSurgicalOutreach.org

Global Surgical Outreach is a 501(c)3 and tax deductible donations can be made at the website or by sending funds to the Larrabee Center, 600 Broadway, # 280, Seattle, WA 98122, Attn: Amy.

Your Facelift and the Stages of Life- The Beauty of Experience

One of our most frequently asked questions is- “What is the best age to have a facelift?” There is no set age that applies to everyone.

We have performed facelifts on patients from their late 40’s to their mid-80’s. Each is individualized for the patient’s anatomy and goals. In a lecture, “My Experience with 5,000 Facelifts”, I discuss the techniques described in The Art and Craft of Facial Rejuvenation. This lecture is never the same however because each time I give it I do more analysis and research to determine how to improve patient outcomes. With experience we have learned to modify our procedure to obtain the best outcome and most natural result for each patient regardless of age.

Our patients in their early 50’s are generally seeking a natural look that will reverse the early signs of aging and build a strong foundation that will last for decades. Our research has shown that facial aging is primarily the result of gravity working on a progressively thinner, dryer, and less elastic skin. These changes are accentuated by sun exposure, smoking, heredity and other factors. The deeper tissues that support the face “descend” and with further aging there is loss of fat or “deflation”. The major lesson we have learned from performing so many facelifts on patients around 50 is that they do last well for decades. The restructuring performed on the underlying platysma muscle and associated support tissue (SMAS) is strong with excellent repositioning in a vertical direction. There are occasional times (a few percent) where a small “tweak” under local anesthesia is done, but most facelift patients do the procedure once and are quite happy long-term. A few seek consultation for another facelift usually about 10-15 years after the first. The changes seen then are mainly skin aging. It is fascinating that when we do a “tuck up” facelift on these patients we usually find the deeper tissues still firm and well structured. We end up doing some very minor tightening on this deeper layer and focus on the excess aging skin. This consistent finding has made me quite comfortable recommending the facelift procedure to patients in their early 50’s knowing it will likely last a long time. There are of course individuals who simply lack good skin elasticity and age more rapidly even after a facelift. I continue to research how to identify these patients and improve their treatment outcomes.

Older patients having a first-time facelift require a larger procedure and generally have excellent results. When there is significantly more skin to remove, incision placement to minimize contour irregularities is crucial. We tighten the SMAS in these patients also and then may need to undermine more of the cheek and neck skin to allow it to drape smoothly. These patients do well, and we can maintain their facial rejuvenation with the many non-surgical methods available including Botox to treat aging signs created by muscle actions and fillers for volume loss.

In our experience, there is a large age range of patients who can benefit from an individualized facelift and within reasonable parameters no one is “too young” or “too old”. What works best in our practice is to perform our deep plane facelift on appropriate patients and then maintain it with good skin care and aesthetic services. Our facelift patients are among our most satisfied, both short and long-term.

Brand New “Aesthetic Studio” 3D System

We are excited to announce our new “Aesthetic Studio” 3D system. We have combined the innovative Microsoft Surface Studio and Quantificare 3D Software with our own graphics to develop a unique system to analyze skin and facial contours, image surgical and non-surgical procedures, and measure our outcomes precisely. This is the single most useful communication and analysis tool I have seen in my many decades of performing facial plastic surgery. Dr. Patel and I are pleased to launch this program by providing complimentary analysis sessions with the Aesthetic Studio to introduce it to our patients and friends. Each session will take about 30 minutes and will provide a skin analysis and discussion of the 3D image. We would like to thank our friends at Microsoft for facilitating the early adaption of their Surface Studio and Quantificare for their support with developing our program.

The Surface Studio was developed for artists and designers to turn their desks into a Studio. It was specifically designed for the creative process. The 28” PixelSense™ Display proivdes a huge canvas for all kinds of work. We can use it upright, or draw on it like a drafting table. The images must be seen to be appreciated.

The 3D LifeViz MiniTM system was developed by Quantificare, a French company, primarily for research in dermatology and plastic surgery. An extremely accurate but portable camera captures the 3D image which can then be viewed, analyzed, and used to simulate various treatments.

Its 3D SkinCare module enables us to evaluate and analyze the skin, generate a personalized, printed report and ultimately to enhance care and communication with our patients.

The 3D Face Shaper module allows us to guide patient aesthetic treatment choices and simulate surgical and non-surgical changes.

We can also measure changes in volume, skin texture, color, and more following our aesthetic treatments. These help us tailor our treatments to each patient and make changes as needed to provide the best results. By measuring our outcomes precisely, we can continue to improve our techniques over time.

The drawing capabilities of studio allow us in a very natural way to sketch surgical options and how we would approach a specific operation for the individual patient. We can work with their photographs or from our own graphical templates designed by our graphic artist Kate Sweeney. Kate has worked on a number of our books and articles so she understands the anatomy, as well as the aesthetic needs.

Facial Plastic Surgery is both an art and a craft. The Aesthetic Studio provides a canvas on which we can design, communicate, be creative, and really see each patient’s face.

The Evolution of the “Facelift”

When I was training in New Orleans we were proud of our facelift technique and had good short-term results. Our procedure consisted of making a skin incision in the crease in front of the ear and behind the ear, lifting (undermining) the skin to the mid-cheek area, placing a few sutures to tighten the deeper layers and then excising the excess skin.  We then told the patient to come back in a year or so for their “tuck-up”- at which time we basically repeated the same procedure but used the scar tissue under the skin to tighten more.  This procedure has survived as the LifeStyle lift and some other named variations but the underlying problem is that it depends on sutures to hold (they don’t) and doesn’t really address the ligaments that keep the tissues from being elevated.   

Later we began a “SMAS” flap technique.  We made the same incisions, lifted the skin, and made a cut through the “SMAS”.  The “SMAS” is a layer of muscle and fibrous tissue beneath the skin of the face and neck.  It can be lifted as a unit and tightened to support the face. The “SMAS” technique gave better and longer lasting results.

Finally, we progressed to variations of the “deep plane lift”.  Our technique we have termed the “deep vector lift” in our book The Art and Craft of Facial Rejuvenation.  We lift the skin a short distance and then go into the deep plane beneath the “SMAS” and elevate the cheek and jowl as one unit. We cut the ligaments that prevent elevation of the tissues. The cheek is elevated in a vector straight up and the neck towards the back of the ear.  This gives a natural, long-lasting lift that is our experience preserves a youthful experience for well over a decade.


In addition to our deep vector lift there are various lifts for specific areas.  The temporal lift is performed behind the hairline above the ear and raises the brow and forehead on the side.  The midface lift is approached through a similar incision but goes into the cheek area and elevates it directly up.  Our neck lift or submentoplasty uses and incision under the chin to remove fat, tighten the muscles, and remove some skin.  It is somewhat limited but in specific cases can give a very successful neck lift.

We now have many options that can be tailored to each patient’s individual needs and goals.  A consultation with detailed anatomical analysis can help determine the optimal procedure or procedures. Incision placement depends on hairlines, sex and other variables.  Procedures such as laser skin resurfacing can be done at the same time.

How to Make Optimal Aesthetic Decisions

Aesthetic Decisions

In the world of aesthetic medicine and surgery there are many options and often contradictory recommendations concerning technologies for facial rejuvenation.  How do we help our patients make optimal decisions in this environment?  We just return to basics-  make a precise anatomical diagnosis and recommend the minimal targeted intervention to address the problem. Perhaps most importantly we combine the best procedures that are specific to the problem or patient concerns.

At a basic level, patients frequently come for aging face concerns such as neck laxity, platysma banding, and “jowls” which are best addressed with some version of a face or neck lift. If you listen closely however they may be under the impression the rhytids (wrinkles) in the cheek or laxity around the mouth will be resolved with the lift. A plan to address the patient’s global concerns might involve laser resurfacing simultaneously, for example.

We like to analyze the face from superficial to deep-

The most superficial layer of the skin is the epidermis commonly referred to in our practice as the ”canvas of the face”.  A facelift will tighten the skin and underlying  muscles but won’t treat the “canvas.”  Our  master estheticians have many quality procedures to improve skin texture, pore size, discoloration and more – these include  Vi-peels, Hydrafacials, microdermabrasions, Intense Pulse Light/Broad Band Light also known as Fotofacial, and they do  non-ablative lasering with Fraxel Re:store which addresses melasma, actinic keratosis, fine lines and acne scarring .   More extensive resurfacing procedures that involve removing all the epidermis and some of the dermis are “ablative”.  In our practice, this usually involves using a fractionated CO2 laser, or a chemical peel such as TCA or phenol.  Both involve about a 10-day healing period where a new epidermis is formed from the remaining skin and deeper skin appendages. 

Non-surgical tightening procedures e.g.  Ultherapy or Profound   work at  deeper levels and create overall rejuvenation, lifting, toning and tightening of the face,   Ulthera is focused ultrasound energy and works on the tissues beneath the skin while Profound is radiofrequency energy.  See Dr Patel’s’ blog on Profound for more information.  

The best option for any patient frequently involves using multiple modalities. Because the techniques work at various anatomical levels they can be combined to magnify the results of any single intervention.

As in any field of medicine a precise diagnosis plus a broad experience with the available treatment options lead to the optimal outcomes.

 

 

Profound RF

Aging is a continuum and to counter it, we may start off with botox or fillers, but eventually work up the ladder to the pinnacle- a facelift. As a surgeon, I can tell you from firsthand experience what a facelift is and how it is done. You actually tighten the deeper layer of the face, resuspend the facial muscles, and excise excess skin. Fillers create support but they do not ‘tighten.’  So what do I say to a patient that has been getting filler for years, that should probably get a facelift, but is not ready to take the plunge? Profound RF.



Profound RF is a combination therapy of microneedling and energy.  Vogue has already named microneedling as the next big thing in skincare; by coupling energy to microneedles, you get a better bang for your buck, and that is exactly what Profound RF does. This radiofrequency technology has 5 pairs of microneedles, which are insulated up until the distal portion. The insulation protects the superficial skin (epidermis) from burns and allows the energy to be concentrated and focused to the layer that needs it the most- the deep dermis. Profound RF uses a very precise and exact science, with respect to the depth of insertion of the microneedles, temperature, and time that the energy is delivered. At these specific settings, the existing collagen is reorganized, and unlike all other technologies- new ELASTIN and HYALURONIC ACID are formed. What does this translate to for you as a patient? Elastin, as the name suggests, brings back the natural recoil of the skin! It truly gives you a lift, not to the same extent as a surgical facelift but for less cost, less downtime, and no general anesthesia- you go through a 1.5 hour procedure and turn back the clock about 5 years!

According to the company, this technology has a 100% response rate! Even on RealSelf, it is one of the few treatments with a 100% worth it rating! Just for comparison, Botox’s worth it rating is 94%! These should be taken with a grain of salt as it is a newer technology and unlike the other treatments, there are less than 50 reviews. However, our results are in and the we see the lift. Most patients have minimal bruising and swelling that resolves on days 5-7 after the procedure. Results can be seen as early as a month but for most, expect to wait 3-6 months to see the full effects!

As another bonus, the handpiece also has a subcutaneous cartridge that can dissolve fat and has shown significant improvement in those who have cellulite. It can be used in combination with the dermal cartridge allowing for one stop shop to both dissolve the fat, tighten the existing skin, and create a lift- all in one visit.

Come in today for a complimentary consultation with myself or one of our aestheticians to see if this therapy is right for you!


Dr. Sapna Patel

Otolaryngology & Facial Plastic Surgeon

 

Submental Rejuvenation

A common concern of patients is the contour of the submental area. Patients desire a strong jaw line and angle between the neck and chin that is about 105-120 degrees. Poor contour of the submental area can be due to any number of anatomical variations including submental fat, recessive chin, lax skin, dehiscent platysma muscle (banding), forwardly placed hyoid bone and more.  Traditionally a surgeon’s main tools to deal with an obtuse cervical mental angle have been liposuction or some more complex surgical procedure. We now have additional nonsurgical procedures such as Kybella, Cool Sculpting, Profound, and Ulthera.

The first step to make the optimal recommendation for a specific patient is an examination that includes analysis of the underlying anatomy.  A significant amount of excess skin would make a surgical recommendation more likely as would an older patient with inelastic skin. Smaller amounts of excess skin and more elastic skin would make Ulthera or Profound potentially excellent treatments. Patients with a “platysma banding” are best served with surgical tightening. On the other hand, excess fat deposits can be well treated with Kybella injections or Cool Sculpting.  Both can provide permanent fat reduction with one or more treatments. 

It is important that those evaluating the patient have experience in the many procedures available- surgical and non-surgical -to make the best recommendations.  The Larrabee Center has the single largest plastic surgery experience with CoolSculpting in our area and one of the largest Ulthera experiences in the nation. Our surgical expertise with face and necklifts can be summarized by the title of Dr. Larrabee’s most recent lecture in Europe- “My Experience with 5,000 Facelifts.”

The possibilities for submental rejuvenation are many and combinations are frequently the best option.  For example one can remove the localized submental fat with CoolSculpting and then “fine tune” the neck contour with Kybella or tighten the skin with Ulthera.

We can discuss all of these options and combinations as needed in a consultation.


Before and after CoolSculpting and Ultherapy

Ethiopia Trip Update


This Fall I returned to Addis Ababa, Ethiopia for my second trip to help kids with facial deformities.

The Black Lion Hospital is the only Head & Neck Surgery resident training program in Ethiopia. The residency program is still in its infancy and will graduate it first class of chief residents in January of 2014. The residents work at both The Black Lion Hospital and The Yekatit 12 Hospital in Addis Ababa. We have been working closely with the Department faculty, led by the Chairman, Dr. Kabede and the former Chairman Dr. Abebe to help develop the residency curriculum and train residents. We have given training the form of both classroom didactics as well as instruction in the clinic and operating room.

Continue reading “Ethiopia Trip Update” »