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” »

Balanced Blepharoplasty

Eyelid surgery or blepharoplasty is our most commonly performed procedure.  A well done operation can immeasurably enhance appearance in general and simultaneously make the entire face appear more youthful. Dr. Larrabee performed the reconstructive as well as cosmetic eyelid procedures at Virginia Mason Clinic and did special training in these procedures at the Moorfield’s Eye Hospital in London UK.  Like many procedures in facial plastic surgery, good craft must be married to a good aesthetic sense and the procedure tailored to each patient’s facial contour. 

Upper lid surgery alone can be performed under local anesthesia on most patients. Youthful lids are full and not hollow. It is important in male patients not to feminize their eyelids by removing too much eyelid skin or fat. Some patients who come in for this surgery have primarily a low brow. The surgeon must make the correct diagnosis and perform a forehead lift as well as eyelid surgery if indicated.  Other patients have “ptosis” which means their actual lid margin is lower and the muscle/tendon that lift the lid needs to be repaired. Other patients have eyelid folds that are asymmetric or too low. Many Asian patients, in particular, want to create or elevate their lid folds.

Because of our Seattle location and Dr. Larrabee’s work in Asia, we have considerable experience performing Asian eyelid operations.  Our goals are not to “westernize” the patient’s eyes but to give them the more open look they desire and place the fold in a natural position that harmonizes with the rest of their face.  Lengthy experience with many types of blepharoplasty allows the surgeon to select the right procedure for each patient.

Lower lid operations can be complex and have evolved over time. We do most fat removal from inside the lids (transconjunctival) and are conservative so we don’t get a hollow look. In some cases, rather than remove fat, it is transposed into hollow cheek areas below the lids (e.g. tear trough deformities). In many situations, laser resurfacing or chemical peels can be used to smooth and tighten the skin of the lower lid. This can decrease the times actual skin excision is necessary.  The specific lower lid procedure recommended will depend on many factors, including the lid support, skin type, and muscle laxity.  A good examination will permit us to make the best recommendations.

Upper and lower blepharoplasty surgery provides an excellent rejuvenation with few complications. It is usually the first procedure patients seek out.  Here are a few patients who had blepharoplasty with or without other procedures.

larrabee-case2before
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The Art of Facial Plastic Surgery

Our most recent book is titled The Art and Craft of Facial Rejuvenation (http://amzn.to/1WqIUsu). The need for skillful craft in plastic surgery is obvious.  The need for art is less obvious but equally important.  Facial analysis is essential to surgical planning, and thoughtful study of a patient’s facial contour described in angles and millimeters (soft and hard tissue cephalometrics) will help set goals and improve results.  We have done research and published in this all important area.
Continue reading “The Art of Facial Plastic Surgery” »

The Northwest Rhinoplasty is Green

The Northwest Rhinoplasty is “Green.”

The Northwest has a unique style in many areas including Rhinoplasty or cosmetic nose surgery. For many decades, the predominant techniques of rhinoplasty involved removing bone and cartilage to make it smaller. In many situations this led over time to pinched, unattractive noses that didn’t breathe well. Surgeons started removing less but also reconstructing key parts of the nose to maintain their strength. This often involved using added cartilage for the septum, ear, or rib. The Seattle community has been in the forefront of developing techniques that use tissue that would be otherwise excised to accomplish some of these same goals. I was honored to direct the international Facial Plastic Surgery course here in Seattle earlier in the decade and then presented some of these ideas at the next global AAFPRS course in Chicago. Basically, the cartilage in the middle and side of the nose is not removed but repositioned to preserve function and avoid a pinched nose. This is a spreader graft formed by using the patient’s adjacent cartilage. It is similar to creating an internal Breathe Right strip:

Breathe Strip

Dr. Murakami from the Mason Clinic develop another procedure where the cartilage in the tip–rather than being excised and discarded–is “turned in” on itself to give the same narrowing but more strength. This is termed a “lateral crural turn-in flap”.

Northwest patients want natural-looking noses that function well, and this “Green Rhinoplasty” that preserves tissue and avoids extensive grafts has been well received. The ideal patient is one with a significant “hump” who has not had previous procedures.

Here are some typical recent patients where these techniques were used:
Before & After 1st One
Rhinoplasty B & A

This is what it looks like during the operation:

Surgical Rhinoplasty view

We have been learning, innovating, and teaching rhinoplasty over the years and around the world. Our conservative but natural approach has been influenced by the needs and desires of our Northwest patients, so it has been a “win-win” for both surgeons and patients.

 

 

How Celebrities Age

Even celebrities cannot escape the aging process! They, too, have the same struggles we have when it comes to stopping the hands of time. Some age better than others, of course. Here are a few examples of the aging process as it pertains to the faces we know and love from the big screen, and what we would recommend if they decided they needed a little additional “help”.

Slide1
Meryl Streep has aged quite well, and is definitely a natural beauty, but if she came to us for a consult we might recommend  a balanced Blepharoplasty.

Slide2
Robert Redford has aged well but has a lighter skin type more prone to sun damage, wrinkles, and discoloration. If he wished to address his sun damage we would recommend  laser skin resurfacing.

Slide3
Morgan Freeman has aged well, and would likely not need any type of cosmetic procedures unless he wanted to help the lines on his forehead with Botox. Darker skin is less prone to sun damage and the resultant loss of elasticity and associated aging changes.

Slide4
Raquel Welch has aged very well. Good skin, youthful fullness, soft tissues, good lid and brow position, and likely good genetics! If she has had any procedures, they have done a great job as she doesn’t look overdone.

Slide6
Brigitte Bardot shows the classic signs of aging. Gravity works over time on a thinner, drier, less elastic skin. Seen are jowls, neck banding, low lid fat and laxity, skin aged by sun. If seen as a consult we would recommend a Facelift, balanced Blepharoplasty, and Laser Skin Resurfacing.

Slide5
Claudia Cardinale shows loss of volume in the lower mid-face, laxity of the jowls and neck with fat accumulation in the neck.  If she consulted we would recommend Liposuction or Sculpture of the neck, Facelift, and Laser Skin Resurfacing.

My Trip to Regensburg, Germany

Claus Walter and Wayne Larrabee in Regensburg, Germany

Claus Walter and Wayne Larrabee in Regensburg, Germany

It has been wonderful to be part of the Regensburg course in Facial Plastic Surgery over the years. Each year it becomes even better. In addition to the energy and ability of Holger Gassner, the support of the entire faculty—including residents and fellows—is impressive. It is difficult to believe that only a few years ago, Holger was a fellow with us at the Larrabee Center, and now he has launched one of the most successful facial plastic surgery centers in Europe. Our book, The Art and Craft of Facial Rejuvenation was well received and sold out early in the meeting.

As always, I like to learn as much as I teach at these meetings. One highlight for me was Janice Pastorek’s discussion of PRP (Platelet Rich Plasma). She showed some amazing results of using the patient’s own platelet rich plasma in combination with IPL (intense pulsed light) to rejuvenate the skin. I also enjoyed a presentation by Grant Hamilton from the Mayo Clinic on the importance of imaging for patient communication. He uses Photoshop and really integrates his imaging into all phases of his rhinoplasty practice. He shared a few Photoshop shortcuts which I will work into our practices in Seattle and London. I also learned some new facial reanimation techniques from Kofi Boahene. Kofi is a facial plastic surgeon at Johns Hopkins with a diverse practice who is also planning a surgical clinic in his native Ghana with the help of the Johns Hopkins Business School.

It was good, as always, to work with and learn from my friends and colleagues from around the world. Peter Hilger, Norm Pastorek, Jon Sykes, Minas Constantinides, Pietro Palma, Miriam Boenisch, Fazil Apaydin, Santdeep Paun, and the wonderful German faculty, who are all talented surgeons and professors. A special moment was an after-dinner talk by Claus Walter, MD (featured in the top photo for this post). Claus is a true pioneer in facial plastic surgery and, at 86 years old, is still innovating. He provided me an article on a new composite graft from behind the ear that contains both bone and cartilage. He is truly amazing.

I am always sorry to leave my family and practice to travel for these meetings, but, in the end, I not only come home excited with new ideas, but also feel confident that our center continues to work at the cutting edge of plastic surgery.

And—it is good to be missed!!

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