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”.

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.

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.

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.

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.

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.

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.

Rhinoplasty in Brazil

Dr. Larrabee is the President of the International Scientific Committee for the International Facial Plastic Surgery meeting in Rio Brazil in May. He will lecture on his Rhinoplasty, Facelifts, and his work on the Global Burden of Surgical Disease. This is a test.

Read his JAMA article on the GBSD

Dr. Larrabee is known for his “Northwest Rhinoplasty” which preserves tissue whenever possible and simply rearranges it – it is thus a “Green” Rhinoplasty.

His facelift technique emphasizes vertical vectors or pull on the deeper structural tissue fixed to strong anchoring points. This gives natural and long lasting results. The technique is described in his book: The Art and Craft of Facial Rejuvenation.
Larrabee Facelift Larrabee Facelift

Below is Dr. Larrabee’s introduction to the meeting. You can also view the site here:

Dear Friends and Colleagues,
These are the most exciting times for scientific change in the history of facial plastic surgery. These changes are global with each region of the world contributing unique insights and developing innovative techniques. The rapid advancement of non-surgical procedures is also a global phenomenon. New aesthetic paradigms, combined with novel devices and products, create novel opportunities to combine surgical and non-surgical treatments. In four magical days in May we will bring together the best facial plastic surgeons in the world to teach and discuss with you every aspect of the specialty from advanced aesthetic procedures to state-of-the-art reconstructive techniques. The program will be very interactive, featuring panel discussions by world leaders in each specialty area in addition to “hands on” courses, didactic lectures, free papers and keynote presentations. The entire spectrum of our wonderful specialty will be covered from lasers and fillers to specific surgical procedures. As always, rhinoplasty will be a core topic throughout our meeting. The last international meeting in Rome was, for me, the most educational in my career. With the same ingredients – a global faculty, interactive sessions, and fantastic organization by the president- this scientific program will meet and may even perhaps surpass the educational standards we reached in Rome. Please join me in Rio for this sentinel meeting in the history of our specialty. We all have events in our lives we remember for their social as well as scientific significance. This will be one of those events. You simply must attend. I would like to thank Dr. Patrocinio and his organizing committee. They have done an amazing job to create this meeting for us. See you in Copacabana!
Dr Larrabee Headshot
Wayne Larrabee
President, International Scientific Committee

Dr. Patel in Honduras

facial fracture
Dr. Patel repairing a mandible fracture
Dr. Sapna Patel Our UW Facial Plastic Surgery Fellow for 2015-2016
Dr. Sapna Patel Our UW Facial Plastic Surgery Fellow for 2015-2016

Sapna A. Patel MD, our University of Washington facial plastic surgery fellow for this year, just completed a mission trip to Balfate, Honduras on March 12-20, 2016 at the Hospital Loma de Luz in Balfate, Honduras. Here are some of her insights from that trip as well as some personal impressions about her mission. The model of combining education with surgery and commitment to follow-up is one we have embraced over the years.

Dr. Johnson grabbed my attention, “Hey, can you come see this patient with me? The other attending recommended a lip switch flap for reconstruction.” Imagining an elderly man with squamous cell carcinoma of the lip, my breath was taken away as there sat a petite, young blind girl whose face was consumed by a disease that I had only read about in textbooks, xeroderma pigmentosum.

The Honduran sun had transformed her beautiful face into one consumed by malignancy – a fate predestined despite all the medical and surgical care we could provide. “She wants to touch your hands,” said her caretaker. I slowly approached, as her hands reached out to my fingers, tears rolled down my face. During my ten years of medical training, I had never felt so moved by a patient. The intraoral bleeding from her dehisced excision site was treated with a simple bolster and figure of eight stitch, realizing that less is more for Deleny. Deleny’s story was echoed in every patient we saw, and it outlined the reality of healthcare in Honduras. The town of Balfate is served by missionary doctors and families providing for the local population. Together, they put this city on the map and made the Hospital Loma de Luz a tertiary care center for patients in the region. More impressive than the organization and high standards for patient care was the selfless dedication displayed by the physicians and surgeons on the front lines. For most Hondurans, aside from the hospital in the capital city of Tegucigalpa, no real options exist.

During our week-long mission trip, we performed a variety of cases from maxillomandibular fixation, gold weight placement for eyelid paralysis, scar revision from a machete wound, cleft palate repair, total parotidectomy, complex thyroidectomies, and even a rhinophyma excision. Each case we saw and the surgeries that we performed affirmed my confidence and knowledge in facial plastic and head and neck surgery. The challenges we faced humbled me each time; I had never done a parotidectomy without a facial nerve monitor. We may not have had the sharpest instruments or the best dissector, but each case was done without reservation to provide the best care possible. We planned accordingly and brought down our needed instruments, including arch bars, an eyelid gold weight, and a lacrimal set, providing sub-specialized care to a population that didn’t have access to it elsewhere. At the end of the week, we reviewed each patient’s case, and could rest assured knowing that our sister team from the Eastern Virginia Medical School would be able to provide follow-up in the fall, creating a continuity of care unlike most mission trips.

These missions, combining surgery with education and organized for excellent ongoing care, provide a good model for humanitarian assistance from the developed to less developed world. On our last day in Balfate, we visited the Children’s Center, which like many organizations in the community is run by a missionary family. As we walked through, there she was sitting on her chair, so innocent and welcoming. She touched my hands and hair, and tears filled my eyes yet again. Deleny had not had any further bleeding. She led us to her shoes and motioned for us to come outside with her. We sat in the shaded area on the porch, as she crawled in our arms wanting to listen to music; her sense of touch, smell, and hearing remained, while the rest were consumed by the disease. We may not have cured her cancer, but at age six, her smiling face as she listened to music reminded me that sometimes the smallest things have the greatest impact. While we are proud of what we accomplished, we also recognize that our team members benefited so much from the experience and will be bringing those new insights back to our home practices.