Louisville Rhinoplasty
Part 5- Closed Rhinoplasty

"Closed rhinoplasty" is a technique that does not involve external incisions and does not deglove the nose from its underlying framework.  Alpine-style mountain climbing is often a swift, and difficult  solo endevour.  Closed rhinoplasty is similar in that it is difficult to learn, perform, and teach. But for surgeons who are facile with the approach, and for the selected nose, the closed approach can offer less swelling, bruising, and down-time.  All without the external scar required with the open approach.  It leaves all of the scars within the nose and does not require the use of nasal packing. It is not for all noses.  Oftentimes an open approach is best suited for noses where a large amount of tip-work is needed or in difficult revision cases.
I decided to come to Louisville for Plastic Surgery training, largely to learn the art of closed rhinoplasty from one of the masters.  I decided to stay because both rhinoplasty and Louisville are very special to me.


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Louisville Rhinoplasty
Part 4- Open Rhinoplasty

"Expedition" style mountain-climbing is like open rhinoplasty.  It is the more widely practiced form of mountaineering.  It involves a large support team to bring supplies and prepare the route up the mountain.  It often utilizes the easiest route (rather than the most direct) route to acheive the summit.  It is easier to utilize and teach.  Unfortunately, it takes a long time and the team swells with people.
Open rhinoplasty is similar.  It is how the majority of Plastic Surgeons choose to perform rhinoplasty.  The exposure prepares the way.  It is easier to learn and teach.  It is often intuitive.  It will get you a result, but it can come at a price.  It requires a scar at the base of the nose.  It is often associated with prolonged swelling, which delays the final result.  But in the end, and like expedition-style climbing, it will get the job done.
Open rhinoplasty involves an incision at the base of the nose and "lifting" the skin completely off the nose.  This often takes hours to accomplish.  Now don't get me wrong, open rhinoplasty is not all bad.  I still use the technique in certain circumstances.   If a large amount of tip work is required, the open approach is usually best.  But in the majority of cases, rhinoplasty can be performed more efficiently and directly, without any external scars, with less down-time, and progression to the final result in a shorter time by utilizing the closed approach.
This view is not universal. Many Plastic Surgeons are only comfortable with open rhinoplasty, and would disagree.  I am passionate about noses, so I will stand up for what I believe....


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Louisville Rhinoplasty
Part 3-  Mountain Climbing and Noses

What in the world does Rhinoplasty have to do with mountain climbing (besides frequent frostbite on the nose)?  Well, the different types of mountain climbing can illustrate the differences between types of rhinoplasty procedures.  Just follow me a bit...
"Alpine" style climbing is widely considered to be the purest form of mountaineering.  It involves simply climbing the mountain, without teams of people to help.  It uses the most direct route up a mountain.  It is the most difficult style and is difficult to teach.  Because there is no help, it has to use the quickest route to achieve the summit.  Summiting a mountain via Alpine-style climbing yields a different, and perhaps better form of success.  Few people are able to climb a mountain, Alpine-style.
"Expedition" style climbing is the more widely practiced form of mountaineering.  It involves a large support team to bring supplies and prepare the route up the mountain.  It often utilizes the easiest route (rather than the most direct) route to acheive the summit.  It is easier to utilize and teach.  Summiting a mountain via expedition-style is a success, but perhaps a different type of success than alpine-style. As we will see in the next few parts, Alpine mountaineering can be equated to Closed Rhinoplasty and Expedition mountaineering can be equated to Open Rhinoplasty.  More to come....


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Louisville Rhinoplasty
Part 2- History of Rhinoplasty

One of the earliest recorded surgical procedures, of any kind, was that of nasal reconstruction in India in approximately 800 BC.  During that time, removal of the nose was performed as punishment. Doctors then used the forehead skin to re-create the nose.  Amazingly, the same technique is still utilized today... or atleast last week for me.  After centuries of little recorded history, nasal reconstruction was reintroduced by the Italians in the 1600's.  They developed techniques utilizing movement of the skin from the arm to the face, in order to recreate the nose.  This too, is still occasionally used (2 months ago for me).  The Germans developed aesthetic rhinoplasty procedures in the 1800's.   All of these techniques have continued to undergo refinements, culminating in the modern rhinoplasty.
As with most of technology and medicine, there is a trend to develop more complex and invasive rhinoplasty procedures.  Although I perform these complex procedures in select cases, it is important to realize that the nose is not the same as an iPhone.  The nose is very delicate (so too is the screen of my iPhone).  The nose usually does not like extensive, complex procedures.  The nose follows a concept that I hold true too, "Just because you can do something, doesn't mean that you should." Many of the basic tenets of nasal surgery were developed thousands of years ago and those principles are still practiced today.  And unlike a new iPhone, new is not always better.  More to come.....

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Louisville Rhinoplasty
Part 1- Me and the Nose

The nose is why I am in Louisville.  The nose is what makes years of surgical training worthwhile.  The nose is what gets me out of bed in the morning.  I decided to pursue Plastic Surgery training in Louisville, KY to learn the art of Rhinoplasty under one of the masters, Larry Florman, MD.  I learned the subtle nuances of a beautiful nose.  I learned how to create a beautiful nose efficiently, with little patient "down-time".  I learned the importance of a patient, family, and close friends noticing a change in the nose, all without having an "operated-on" appearance.  I learned to respect the nose.

Rhinoplasty is often considered one of the most difficult procedures in Aesthetic Plastic Surgery.  The reasons are numerous, but most importantly is the need for patience.  The changes made in the operating room do not fully manifest for many months.  There are ways to make rhinoplasty easier, but they come at the price of longer procedures and external scars.  Unfortunately, the nose does not like scars or long procedues.  Hence the importance of efficiency and respecting the nose.

The subtleties of Rhinoplasty will be covered in depth in the next sections.  I hope at the end, one can have a healthy respect for Rhinoplasty and understand a little more why I love the nose.

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Louisville Forehead Lift/ Brow Lift
Part 2- Treatments

There are various options for treatment of the forehead and brow. The decision regarding the treatment depends on the exact problem.  A long forehead can be shortened (coronal brow lift), but a short forehead cannot be lengthened.  Eyebrows that are too low can be raised (coronal brow lift, endoscopic lift).  Deep wrinkles between the brows can be temporarily paralyzed (neurotoxins) or removed (limited incision muscle resection).  Deep horizontal wrinkles can be temporarily paralyzed (neurotoxins) or removed (coronal brow lift). Asymmetric brows can be brought into harmony (direct brow lift).

Coronal brow lifting is often considered the "gold-standard".  It has been performed for many years and gives predictable results, which are long-lasting.  Unfortunately, many patients are scared away when I tell them that it requires an incision within the scalp that spans from ear-to-ear.  I can honestly say that the scar can be barely visible, but by this time, some patients are already glassy-eyed.  For those willing to accept the minor scar, coronal brow lifting is often the best choice.

For those "glassy-eyed" patients who want to run out of the office at the thought of a coronal brow lift, endoscopic forehead lifting may be an option.  This utilizes small cameras inserted through the scalp, followed by lifting of the brows.  This is a reasonable option if the brow is too low, but it will not change the length of the forehead.  Although endoscopic lifts have been shown to provide long term lift of approx 5mm, I prefer to think of it as a method of keeping the brows from sagging any further, rather than long-term lift.

Neurotoxins (Botox, Dysport, Xeomin) have transformed the state of brow and forehead lift.  These neurotoxins can be used to temporarily improve wrinkles of the forehead and between the brows.  The use of neurotoxins avoids a surgical procedure and can be performed in a short period of time.  If more permanent results are desired, limited-incision muscle resection or forehead lifting may still be performed.  Neurotoxin use may also elevate the lateral brow, but will not dramatically change the brow position or the length of the forehead.

Overall, there are many options for forehead and brow rejuvenation.  The use of neurotoxins has changed the landscape- many are choosing to have an easy, temporary result  rather than a surgical, permanent result.  Because of the variety of treatments, forehead and brow rejuvenation can result in long-term, natural appearing results.

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Louisville Forehead Lift/ Brow Lift
Part 1- Goals

The optimal (youthful) appearing forehead and brow are difficult to quantify.  In fact, the ideals have changed over time.  Years ago, the ideal was based solely on brow position, as there was no good treatment of forehead wrinkles.  In that time, the goal was a high, mid brow arch.  Unfortunately, this resulted in the chronically "surprised" look.  With the advent of neuromodulators (botulinum toxins), the environment has drastically changed.  A youthful forehead is gently sloping, without deep vertical or horizontal wrinkles.  Brows differ in men and women.  Optimal brows in men are typically more horizontal, without a significant arch.  The brow is centered on the supraorbital rim (bony ridge above the eye).  Optimal brows in women lie above the supraorbital rim.  Although there are many variations, the optimal brow is approximately 2.5cm above the mid-pupil (center of the eye).  The brow continues to arch superiorly, and peaks at a level in line with the lateral limbus (the outside of the pupil).  There are now many different tools available to address problems of the forehead and eyebrow.  All of these can now be used to generate a natural, youthful look.  All-the-while, avoiding the permanent "surprised look".  The surprised look is great when watching a horror film,  not so much when looking at your credit card statement.  More to come.....


Guyuron, Bahman, and MichelleLee. "A reappraisal of surgical techniques and efficacy in forehead rejuvenation." Plastic and reconstructive surgery 134.3 (2014):426-35.

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Scar Prevention
Part 6- To Sum It Up

As we have seen, there are many options for scar treatment and prevention.  Many of which are untested or unproven.  The choices are:  spend hundreds to thousands of dollars on unproven therapies, or, reasonable, cost-effective treatments which can provide excellent results. When recommending therapies to my patients, I have to go with what is safe and effective, based on sound scientific data.  In the end, it always comes down to what I would recommend for my own family-
1) Sun protection- All scars need adequate sun protection (sunscreen of SPF 30, with correct application) for atleast one year after surgery
2) Plain-paper taping of incisions for atleast 6 weeks
3) Scar massage
4) Finding a good surgeon to perform your procedure
5) Save your money for a vacation, away from cellphones, the internet, and the Real Housewives of Beverly Hills.
More to come...

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Scar Prevention
Part 5- Snake Oils and The Placebo Effect

Scar treatment and prevention has been subject to countless untested and unproven therapies.  Patients often swear by treatments that are known to have little to no effect.  Indeed, good studies have demonstrated both subjective and objective improvement in various diseases, when treated with placebos ("sugar-pills).  Recent studies have documented improvement in lung function in those with asthma, when treated with placebos.  Other studies have shown that placebos may be 80% as effective at treating depression as standard medical therapy.  The reasons behind this are complex and poorly understood.  Expectancy plays a role- subjective improvement because you expect improvement.  The expectancy effect is real.  It causes changes in brain chemistry, and can stimulate the production of neurotransmitters, similar to that caused by medications.
So, what does this have to do with scars?  There are countless untested and unproven scar therapies being marketed.  Whether scar improvement is due to the "therapy" or to the placebo effect, is anyones guess.  Often, just getting a patient more involved in their treatment, leads to better results.  Unfortunately, the placebo effect can be taken advantage of.  Scar treatments can easily cost thousands of dollars.  These treatments may sound exciting and complicated- scar creams that contain estrogens, steroids, growth factors, and vasodilators.  Unfortunately, there is little to no data that these are any better than lotion from Victoria's Secret.  So, in the end, if I just want to do something,  it is a good excuse to go to Victoria's Secret.  More to come...

Dutile, Stefanie, Ted JKaptchuk, and Michael EWechsler. "The placebo effect in asthma." Current allergy and asthma reports 14.8 (2014):456-456.

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Scar Prevention
Part 4- Sun Protection

A hyperpigmented or red scar is much more noticable than a hypertrophic (raised) or widened scar.

Many things can lead to a reddened scar, including infection, wound tension, inflammation, and UV-exposure.  Of these things, UV-exposure is one of the only places that a patient can intervene.  If a fresh scar is exposed to significant sunlight, it tends to turn red.  To make things worse, it tends not to fade back to the color of the surrounding skin.  After I explain this to patients, the next question is whether they need to use SPF 75 or 100.  The marketing of sunscreens is in flux at this point.  In fact, there is a push to limit the advertised SPF to 50.  At these high levels, there is very little difference.  In fact, there is little difference in the incidence of sunburn between SPF 15 and SPF 30, if applied correctly.  "Applied correctly" is the key term.  Most people do not apply sunscreen in sufficient amounts or re-apply often enough.  If applied incorrectly, like I do, the incidence of sunburn is decreased when SPF 30 is used, compared to SPF 15.  In the end, I recommend sun-protection (SPF 30 sunscreen) to patients any time they are in the sun for atleast the first year after surgery.  Good sunscreen can be expensive, and costs a fortune when you need it the most- on a cruise or at the ski resort.  I still flinch at the time I had to grab a small bottle at the Hilton Head marina.  Nevertheless, it is always cheaper than a scar revision procedure or any of the unproven scar creams on the market.  More to come...


Due, Eva, et al. "Effect of UV irradiation on cutaneous cicatrices: a randomized, controlled trial with clinical, skin reflectance, histological, immunohistochemical and biochemical evaluations." Acta dermato-venereologica 87.1 (2007):27-32.
Pissavini, Marc, and BrianDiffey. "The likelihood of sunburn in sunscreen users is disproportionate to the SPF." Photodermatology, photoimmunology & photomedicine 29.3 (2013):111-115.

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Scar Prevention
Part 3- Taping
Semi-occlusive dressings have been shown in multiple studies to be associated with improved scar appearance.  This can be acheived in a variety of ways, most notably, the practice of taping over incisions.  The reason taping improves scar appearance is not well understood, but thought to keep scars hydrated and decrease tension across wounds.  More recent data shows that there are small nerve fibers in scars that can sense pressure and tension.  When tension is sensed by these fibers, neurotransmitters are released that ultimately lead to changes in the architecture of scars and worsens their appearance.  Taping acts to shield a scar from activation of these fibers, decreases wound tension, and keeps the scar hydrated.  Regardless of the mechanism, prolonged taping of an incision has been shown to improve the scar quality.  Other recent data shows atleast equivalence to silicone-based gels/ sheeting.  Silicone-based preparations can be very expensive, wheras, a roll of paper tape sells for about $3.00 at Amazon. This data is not widely publicized, as the market for "scar creams" is a multi-million dollar affair.  No company gets rich on $3.00 rolls of paper tape.  In the end, I generally recommend the simple act of taping incisions for 6 weeks after surgical procedures.  More to come...

Yagmur, Caglayan, et al. "Mechanical receptor-related mechanisms in scar management: a review and hypothesis." Plastic and reconstructive surgery 126.2 (2010):426-434.

Tollefson, Travis T, et al. "Comparison of effectiveness of silicone gel sheeting with microporous paper tape in the prevention of hypertrophic scarring in a rabbit model." Archives of facial plastic surgery 14.1 (2012):45-51.

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Scar Prevention
Part 2- Vitamin E

Immediately after I explain the role and alternatives to silicone-based scar preparations, many patients ask about the use of topical Vitamin E.  Afterall, most grandmothers swear by it (atleast mine does).  Vitamin E is a tocopherol with antioxidant properties.  It is theroized to act by inhibiting collagen formation, inflammation, and fibroblast proliferation (all of which are needed in normal wound healing).  Only a few studies have demonstrated any benefit, and only in conjunction with other therapies.  Most studies have shown no improvement and a high prevalence of contact dermatitis (rash).  Nevertheless, the placebo effect is real- some patients feel improvement, just by doing something.  So in the end, I generally do not recommend the use of Vitamin E for scar treatment or prevention.  However, I am not one to argue with grandmothers.  More to come...

http://www.ncbi.nlm.nih.gov/pubmed/21856542
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Scar Prevention
Part 1- Silicone Scar Creams

Wound healing and scar formation is a very complex process.  Poor scar healing can result from a variety of factors.  Due to the different factors, there is no single therapy that leads to elimination of scarring. Nevertheless, most patients are looking for the "magic cream".  The most widely marketed scar preparations are silicone-gel based.  Silicone sheets and silicone gels are widely considered to be the only non-invasive therapy for scars.  Many studies have shown improvement in scar quality and decreased risk of poor scarring (hypertrophic-scarring, keloids).  Although the exact mechanism is unknown, it is thought that the silicone acts as a sealant and keeps the scar hydrated.  Hydrated wounds are generally known to result in imrproved scarring. So in the end, silicone preparations have a role in scar management.  However, there are many other factors that influence wound healing.  As we will soon see, other therapies may just effective as these silicone products.  More to come......

http://www.jprasurg.com/article/S1748-6815(14)00173-9/abstract

Finally, a thoughtful and amusing look at untested and unproven skin care products
Nerium- Barefacedtruth.com