Eva Sheie (00:03):
The purpose of this podcast is simple. We want you to get to know your doctor before meeting them in person, because you're making a life-changing decision, and time is scarce. The more you can learn about who your doctor is before you meet them, the better that first meeting will be. There's no substitute for an in-person appointment, but we hope this comes close. I'm your host, Eva Sheie, and you're listening to Meet the Doctor. Hello and welcome. On today's Meet the Doctor, I have my friend, my longtime ride to the airport, Dr. Bill Portuese, who is a facial plastic surgeon in Seattle. Hello.

Dr. Portuese (00:43):
Hi, Eva. How are you?

Eva Sheie (00:46):
It's good to see you.

Dr. Portuese (00:47):
Always great to be seen by by you. <laugh> I've known you a long time and you've been very helpful to me over the years in my practice.

Eva Sheie (00:55):
Oh, thank you. It gives me a lot of joy to be helpful to good doctors. So it's been great in kind of solving big problems with you over the years, even though most of the time you don't really listen to me <laugh>, it doesn't stop me from being helpful again later. <laugh>.

Dr. Portuese (01:15):
Well, thank you for all your help over the years.

Eva Sheie (01:18):
You're welcome. You're a tremendous resource to your patients and you're sort of like the Energizer Bunny and you just keep going and going and going <laugh>. And I know that you focus on rhinoplasty a lot and several other things. Kind of give us the lay of the land. What's your practice look like today? And then we'll kind of go backwards and, and talk about how you got there.

Dr. Portuese (01:43):
So I'm in private practice. I started and founded the Seattle Facial Plastic Surgery Center about 30 years ago. And today, um, we, we have our own surgery center happens to be Medicare certified and then Washington State License for Patient Safety. And, um, my practice is pretty much facial cosmetic surgery, predominantly based with on rhinoplasty and specifically closed rhinoplasty, which is where the incisions are completely made on the inside of the nose. Um, I also do eyelid surgery, facelifts, chin implants, cheek implants, brow lifts, but basically facial aesthetic surgery in a private practice setting. We're in our office in surgery center located in downtown Seattle, right across the street from the major hospital here in town.

Eva Sheie (02:32):
Why closed rhinoplasty specifically? I've never heard you actually say that before.

Dr. Portuese (02:37):
Well, I've really become a, when I, in my training 30 years ago, I did both open and closed rhinoplasty and realized there's the open rhinoplasty. There's, there's just a better way of doing things. There's a less invasive way to do the nose. In other words, I don't have to place an incision on the cella across here and then peel the whole nose up to be able to enable to make the required changes in the nose. And so if I can make all of the incisions completely on the inside, number one, patients will heal better, faster, not have to worry about a skin necrosis in the columella because you've divided that and you heal faster because you don't interrupt the lymphatics to that area. So it's just a better way to do a rhinoplasty. And there's a couple of things that what happens with open rhinoplasty, it's hard to control the upward rotation to the nasal tip when you are doing either sutures or to, to the tip cartilages or removing some extra cartilage in the tip it, you get rotation upward rotation of the nose.

Dr. Portuese (03:46):
And it's also with closed rhinoplasty, it's easier to control that and that upward rotation. The other problem with open rhinoplasty is many surgeons don't address the hanging columella. That's where the cella itself here hangs down too much because the first thing that happens when we shave a hump down is that the columella bow strings downward. And with open rhinoplasty, it's very difficult to address that hanging columella. So the, the nose looks bottom heavy, if you will. So with closed rhinoplasty you can address those two things. One, the hanging columella by trimming excess columella skin and cartilage. And you can control the rotation or de-rotation. It's easier to de-rotate the nose when you over-rotate it with closed rhinoplasty because you can take this extra skin down here. It's like a sort of like a, a seesaw, if you will. You can, you can de-project and de-rotate and not have to worry about both the, the over rotation in the hanging columella, if that makes any sense. In a, in a layman's terms, it gets, rhino, the problem with rhinoplasty, it gets kind of technical. So I'm trying to break it down into easy terms that patients can understand.

Eva Sheie (05:01):
Do people find you for this specifically? For the reason,

Dr. Portuese (05:04):
No, I have patients mm-hmm. <affirmative>, I have patients flying in from all over the United States because they really, when they start doing their homework, they realize there is, there's two types of rhinoplasty closed versus open. But the important component is really the closed versus open debate is really only about the, the approach on how you get into, into the nose. So do you make the incisions completely on the inside or do you make 'em on the inside and the outside? It's the approach. All the little maneuvers we do inside the nose, like refining the nasal tip, shaving down a hump, putting in some spreader grafts, you know, making little cuts in the nasal bones called osteotomies. All of those little maneuvers can be done with either open or closed, the open or closed, it's only about the approach on how you get in the nose, not what you're doing inside.

Eva Sheie (05:57):
When you meet with people who are considering rhinoplasty, especially if they're coming from far away, do you do a virtual consultation before they get on a plane? Or how do you handle that?

Dr. Portuese (06:10):
Well, we always have to talk about before the pandemic and after the pandemic because those are really two different environments in this business, especially with, with rhinoplasty. So prior to the pandemic, I was not all that comfortable doing Zoom calls or FaceTime calls with patients from across the country. I, that's me personally, I wasn't that comfortable with it because I wanted to see 'em in person feel in touch on their nose. Well the reality is Zoom calls are here to stay and so I have pivoted during the, we, you know, we were shut down for two and a half months during the Covid pandemic. So during that time we basically had to pivot because we had nothing else to do. We were completely shut down. The governor's orders shut us all down in the state of Washington, so for all elective surgery. And so we just had to pivot and started doing Zoom calls.

Dr. Portuese (06:58):
We'd do the, so the patients would send us their photographs, their demographics and all their information about their, you know, their health history. And we would do computer imaging, send that back to 'em, and then we would hop on for 30 minutes and do a zoom call. I got comfortable with it, patients have got comfortable with it, and then they just come in the day before for their surgery. And if they wanna see me the day before, that's fine, or just meet me the morning of surgery, that's fine. They hang out in town for a week and then take their cast off. They go back, fly back home, and then they send, they, we ask them to send us pictures at one month, three months, six months in a year just to follow up with them, make sure they're doing okay.

Eva Sheie (07:38):
They send their own pictures.

Dr. Portuese (07:39):
They send their own pictures in, yeah.

Eva Sheie (07:41):
If something goes wrong, how do you handle that?

Dr. Portuese (07:44):
Well, really the only thing that goes wrong could be a nose bleed situation. Those are pretty rare. And we give patients a bottle of Afrin nasal spray to go home with after the surgery. So they take that and I just tell 'em to carry it with you on the airplane, make sure if you get a nose bleed, use this. And 95% of the time that stops a nose bleed. It's very rare to ever have to put packing in the nose after a rhinoplasty. Very, very rare. Yes, it happens, but it's once every three to five years. So it's, it's very rare. Packing would, could be done somewhere, you know, in another city, you know, an emergency room doctor could put a little pack in there and then for a day or two until the nose bleed stops, there's always a small chance, you know, it's five to 10% chance we have to have patients come back in a year at one year and, um, consider doing a touch up procedure where they've got a little nuance or a little bump or a little dent or some little nuance.

Dr. Portuese (08:41):
And sometimes you can only see those in certain angles, but that's a pretty low percentage rate of five to 10%. But those issues occur because, you know, skin, bone and cartilage is living tissue and the nose looks great when I'm all done, but at six months, eight months, 10 months down the road, you get a little bump that comes up here cuz bone's living tissue, if you break your wrist, you grow more bone cells. Most people think bone is dead tissue. It's not, it's, it's actually alive. That's why when you break your wrist, you grow more bone cells in your wrist heals. Same thing here. You can grow more bone cells after a rhinoplasty. It's outta my hands. These, these little bumps don't even show up for eight or 10 months.

Eva Sheie (09:21):
Is that also why your nose keeps getting bigger as you get older? Is that even true?

Dr. Portuese (09:27):
It, I don't think that's true. I think the ligaments in the nose loosen. So especially if you have a droopy tip and your, and every time you smile your tip droops, I think that's sort of tethering or stretching your nose out a little bit vertically so your nose will lengthen because of the ligaments that loosen up over time.

Eva Sheie (09:47):
We're just learning all kinds of good things today.

Dr. Portuese (09:49):
Now the skin and the tip of the nose can thicken here based on, you know, rosacea. Yeah, that can happen. But the actual, I don't think the cartilages really grow,

Eva Sheie (10:00):
Definitely not the bones.

Dr. Portuese (10:02):
No

Eva Sheie (10:03):
<laugh>,

Dr. Portuese (10:04):
The little bony bumps that that we have to come back and do a little touch ups on. Those are just, that's just, that's part of the, part of the healing process.

Eva Sheie (10:13):
No, you're sort of insta-famous for your reveal videos that you do. How did this start?

Dr. Portuese (10:21):
So about, I don't know, four years ago or so, maybe five years ago, I just realized that that Instagram was a popular medium and a lot of patients are on that medium. And I happened to be down in Napa Valley wine tasting with two close friends, one of which was Tom Siri, the CEO of realself.com, and Paul Nassif, who's the surgeon on the TV show, Botched. And I think my wife had taken a picture of the three of us standing in a vineyard in Napa Valley. Didn't think too much about it. And I, um, when we got home, I just told my staff who are just starting to post on Instagram, why don't just throw this picture, put this post, this picture on Instagram and just see what happens. And that week, within a few days, three patients were in my office that said, I saw you with Dr. Botched in Napa.

Dr. Portuese (11:22):
I went, wait a minute, three patients in one week have already seen that picture. I said, this is a pretty powerful medium. Okay. So that was the first section. Now I realize, realize that validated that Instagram is a popular platform, especially for rhinoplasty. Then I decided, well, what's the aha moment? What's the emotional moment that a woman goes through with a rhinoplasty? It's taking off the cast. It is a very emotional moment. Matter of fact, I had a patient, I just took her cast off 15 minutes ago. She was breaking down crying. She's from Spokane, Washington, had come over here and, and, uh, you know, five hours away for me to do her, her rhinoplasty. She immediately took the cast off, she started crying because it'd been sort of a, I don't know the right word, kind of a mini obsession.

Dr. Portuese (12:10):
She had thought about it for a long time, for like 10 years. And I finally just took that obsession away and she's just so thrilled. So I realized that those taking the cast off is an a real aha moment. And so I just, we just captured that with patient permission and started posting on Instagram and TikTok and, and it just became some of those posts that were very emotional became very, very viral. And next thing you know, when they, when they go viral with a million or 2 million or 3 million views, the phone just starts ringing off the hook. So, and then, then I decided to have some fun with the casts themselves. And so I've designed many different colors and styles of casting material to be used in those videos as well. Instead of just the plain generic little plaster cast or the little, little, they're called, um, thermoplastic cast that respond to warm water. I, I wanted to just have a little fun with it. And the patients get to pick their own cast prior to the surgery.

Eva Sheie (13:22):
Are you still making those yourself?

Dr. Portuese (13:24):
We do. Mm-hmm. <affirmative>. Yeah, we do.

Eva Sheie (13:27):
So you go home at night and just <laugh> add some flair to some casts?

Dr. Portuese (13:31):
Oh yeah. I, I, uh, I'll, uh, I've had, um, inquiries from many surgeons around the country where I, they can buy these casts and I tell 'em that they're not for sale and it's proprietary.

Eva Sheie (13:45):
Etsy <laugh>, put 'em on Etsy, <laugh> <laugh>,

Dr. Portuese (13:50):
I'll keep my day job. <laugh>

Eva Sheie (13:53):
<laugh>. Do people make requests like, I want a leopard print, I want

Dr. Portuese (14:00):
Oh yeah.

Eva Sheie (14:01):
Barbie. Yeah.

Dr. Portuese (14:02):
Yeah. Or they want a Seahawks cast or, oh, for

Eva Sheie (14:05):
Sure.

Dr. Portuese (14:06):
Uh, Mariners cast or a Kraken cast or, yeah, a lot of sports fans up here.

Eva Sheie (14:12):
<laugh>. Yes. I live with one <laugh>. In the past we've talked a lot about rhinoplasty and mental health and I think your example of, of your patient and talking about 10 years of thinking about this is just such a good representation of how much mental noise goes into something like that. And it's not just noses, it's things like being overweight. You think about being overweight all day every day. It's like your predominant thought pattern, if that's you, and I'm, I can relate to this thinking, but there's also people who kind of take it too far and you've seen that too. So how do you kind of find the balance between somebody who is healthy about wanting to change the, the look of their face or their nose and somebody who really needs a different kind of help?

Dr. Portuese (15:08):
This is a very important topic, and every busy rhinoplasty surgeon in the country has to deal with this issue. A healthy obsession is okay. I mean, you're, you're kind of, you gotta stay focused on something, I understand that. But once we've done the nose, many patients take it to another obsession where they're looking in the mirror a hundred times a day, 200 times a day. And that is an extreme form of obsession. And it's, there's something called body dysmorphia, and it happens. And the problem is the doctor has to recognize it and more importantly, the patient has to recognize it. And even more importantly is once patients recognize it, which is difficult, they then have to realize, well, I might have a little problem here. I'm, I'm probably obsessing a little bit too much if I can't go out of the house. All I can think about my entire day is just thinking about my nose, whether I've had surgery or, or haven't.

Dr. Portuese (16:07):
But usually they become much more obsessed after the surgery. And Michael Jackson probably had the same body dysmorphia. There is professional help out there for this issue. There's a, a book called The Broken Mirror that's available on Amazon, The Broken Mirror. And there is actually a website that patients can take their own self-test and be more self-aware. And there's a whole website that just talks about this issue. And it's called bdd foundation.org. It's the Body Dysmorphic Disorder Foundation website. And I always try to direct patients to that. I think the important thing is you have to recognize that there is a problem. And to get through this, if you have body dysmorphia, you have to get professional help. And you're probably gonna have to be on some type of medication to help break the obsession. Because without both of those, I think you're gonna be doomed to, to failure.

Dr. Portuese (17:16):
And if most reputable plastic surgeons, spatial plastic surgeons, if they know a patient has body dysmorphia ahead of time, most of us will not operate on that patient because you're just doing the patient a disservice until that the dysmorphia is, is treated, those patients are gonna be miserable because their entire life revolves around their nose. And with rhinoplasty in the nose is the nose. And I think the hair are two hair cutters see it as well. I think those are the two biggest areas of the body that people tend to focus and obsess on excessively. Anyway, that's a long answer for a short question.

Eva Sheie (17:59):
That's a good answer.

Dr. Portuese (18:02):
So the bottom line is if patients realize that they have an over obsession, it's probably not a good idea to undergo any type of cosmetic surgery. And, and as perfectionistic as I am, and most surgeons are, the, the problem is, even with the nose, there is no perfect nose. It's not a block of marble, it's not a block of wood or it's not a block of plastic. It's two nasal bones and, uh, five cartilages and wrapped in, in skin. And it's a three-dimensional object and it, and it heals three dimensionally. And so there's never gonna be the perfect nose, just, you know, we try to get patients 85 to 95% better. We never get you to a hundred percent because that, that there is no perfect nose.

Eva Sheie (18:48):
Do you think 3D imaging tools help that situation or hurt it?

Dr. Portuese (18:54):
I think, you know, 1D, 2D or 3D imaging, all of that's fine. And I think it's, it's the education process. Okay, here's what computer imaging can do for you potentially. So it's a communication tool so the patients can understand what a new, a new nose would look like upon their facial features. That's the first component. So it's a great educational tool, but the surgeon who produces those digital images has to at least be able to come fairly close. Not exact, but fairly close to those images. And that's what we strive to do. We strive to come as close as we can to those predicted images. And most of the time patients will actually say, you know what? My nose looks better in person than it did in those, the imaging software that, that you did for me back, you know, before the surgery. Most patients.

Eva Sheie (19:49):
I heard a story about a retired facial plastic surgeon the other day, and before there were even computers, he was taking photographs, <laugh>, getting them developed in a dark room, bringing the patient back two weeks later, and then drawing on the photographs to show them how it would change. So I, he's like the original 3D guy. Yeah.

Dr. Portuese (20:13):
Yeah. Listen, I started private practice in 1991. In 1993 I started doing computer imaging with a, a high eight handicap, taking pictures with that, with a very elemental software program like Photoshopping, that is for computer imaging. And I was using it on a 4 86 computer <laugh>. So it's come a long way.

Eva Sheie (20:39):
And Bill Gates was helping you?

Dr. Portuese (20:40):
Yeah. No <laugh>, no, uh, no. But it was, it was very early on trying to figure out how to make this thing work <laugh>, you know, and, and basically it would work better, much better from the side profile. We were at that time just doing the side profile of the nose just cause we put it on a, a blue background and had something to work with and you could kinda shadow the bump away, but the resolution had to be good. And then the software was pretty clunky, especially on an old Dell 4 86.

Eva Sheie (21:07):
Wow.

Dr. Portuese (21:08):
Back in early nineties. Yeah.

Eva Sheie (21:10):
Wow. We've come so far.

Dr. Portuese (21:12):
Oh my goodness.

Eva Sheie (21:14):
So there's another first that I wanna ask you about. It sounds like you were the first to do computer imaging too. I didn't, didn't predict that one. You were probably one of the first to really make this reveal video. You were also the first one answering questions on the original realself.com, which was you started right before I did. So you, you were answering questions like as soon as there were questions to answer, right?

Dr. Portuese (21:38):
Correct. So I had the really good fortune of being introduced to a gentleman named Tom Siri who just happened to live in Magnolia, my own neighborhood in Seattle, cuz he lived in Magnolia. And he had, when I first met him, he had shown me this new idea called RealSelf on his laptop computer. And I looked at it, I said, Hmm, that's a pretty good idea, you know, doing social media on the internet for cosmetic surgery. And then, um, you know, within a year or two we'd struck up a pretty good friendship and about a year or two later he goes, well, we're gonna start doing q and a questions and answers on this RealSelf platform. I go, that's a good idea. He goes, uh, Bill, I'm gonna give you a couple of questions. I'm gonna give you three questions and I want you to just do your best to answer 'em. And I, I had to, I just dictated 'em and sent 'em an email back. This was back in around, well the company formed, started in, in 2006 and I think it was probably 2007 or 2008 when he first gave me the first couple of questions. And the first three questions were, it's like a, it's like a slow pitch softball <laugh>, what is a rhinoplasty? <laugh>,

Eva Sheie (22:55):
What is rhinoplasty?

Dr. Portuese (22:56):
What is rhinoplasty? What's a blepharoplasty and what's a facelift <laugh>? And yes, I was the first person to ever answer questions on the RealSelf platform. <laugh>

Eva Sheie (23:05):
Well, I would've been working in the office at that time, so, you know, we were writing tons of content every day. There was only five of us and we were all doing all the jobs.

Dr. Portuese (23:14):
There's now two, what, 220 employees?

Eva Sheie (23:17):
I don't know.

Dr. Portuese (23:18):
I don't, yeah,

Eva Sheie (23:19):
Yeah. But Tom did all the jobs himself back then.

Dr. Portuese (23:23):
Yeah,

Eva Sheie (23:24):
Yep. Answering questions. That was the beginning of, I mean, a lot of that, um, I don't really talk about it much, but I had already been building websites and I knew what kind of content people were responding to. So my role at that time was to tell Tom, here's what kind of content people want. Which, and I may have very well said, we just need, you know, Cora was also really big at that time and that was just a site full of questions and answers. So that was influencing our thinking.

Dr. Portuese (23:54):
Yeah,

Eva Sheie (23:55):
Yeah. And then, and then we added photos and then we added reviews. Okay. So before you have to run and see another patient, I want to ask you who you are outside of work, because I know you have a tremendous number of other interests.

Dr. Portuese (24:13):
I do. The type of hobbies that I enjoy are, I, I do a lot of fishing, but several different kinds of fishing. So fly fishing for trout and Idaho or Eastern Washington is a favorite of mine. I do go up to either Alaska or Canada, go salmon fishing, trolling for salmon fishing. I'm an avid snow skier. I love snow skiing in Washington, Sun Valley, Idaho. Do some hiking, forage for mushrooms up in the Olympic Peninsula. I also am doing a salmon enhancement program and I, on a little cabin that I have over in, uh, on Hood Canal and that there's a natural aquifer creek that comes down through my property and I'm able to raise anywhere from on an educational permit. I'm raising baby chum, fall chum salmon through a permit that, so I'll get 50,000 to a hundred thousand baby chum salmon in a given year. And I grow 'em up from the egg phase all the way till they're about two inches long and release 'em from the freshwater into the saltwater and then they come back four years later.

Eva Sheie (25:28):
What?

Dr. Portuese (25:29):
Yeah. Yeah. That's kind of a fun little project. I'm just, they just like, within the last few weeks just went out. Usually around April 1st they get released in there. They transition from fresh to salt water real easily.

Eva Sheie (25:42):
Yeah. But how do they know how to come back?

Dr. Portuese (25:45):
That's the $64 question. So salmon, there's an out-migration and an in-migration. So there's a sequence of steps that salmon go through on the way out. So there's chemical signatures in the water, like the sense of smell and they can smell, they know where they're at based on, you know, this creek here, you can imprint it. They get imprinted on it. You can imprint a salmon on a garden hose <laugh> in that fresh water. They'll always come right back to the, where they were, where they're born in that freshwater, they're born and die in freshwater. But they'll always come back to that, almost always come back to that little creek where they were born. But they'll go by, you know, 10 or 20 or 30 other creeks. And finally that creek right there, that's, that's my home because it's a, there's a signature scent in the water and they can go right the home, right back to it. The issue, the more perplexing issue is how do they figure out when to come back? Cuz they're coming back the third week of November, four years from now.

Eva Sheie (26:46):
That is miraculous.

Dr. Portuese (26:47):
How do they figure that out? I mean, if you didn't have, if I didn't have a calendar, I wouldn't know any better where to go at, uh, the third week of November and four years from now, I, I'd be lost in outer space.

Eva Sheie (26:59):
Wow.

Dr. Portuese (27:01):
<laugh>. It's fascinat it's a fascinating hobby. And the more you learn, the more you want 'em, learn more.

Eva Sheie (27:08):
It sounds like it.

Dr. Portuese (27:10):
Yeah. So that keeps me busy when I'm not in the office.

Eva Sheie (27:15):
Thank you for sharing so much of yourself with us. We'll have to have you back and talk more about all of these amazing things. Where can people find you if they wanna learn more about coming to see you as a patient?

Dr. Portuese (27:28):
Our website is seattle facial.com. The patients can look me up on RealSelf on my RealSelf profile, realself.com. My Instagram account is, uh, hashtag Dr. Bill Portuese. And, uh, our TikTok account is the same hashtag Dr. Bill Portuese.

Eva Sheie (27:47):
We'll put all those links in the show notes. Thank you so much Dr. Portuese. So good to see you today.

Dr. Portuese (27:53):
Thanks Eva. We'll talk soon.

Eva Sheie (27:58):
If you are considering making an appointment or are on your way to meet this doctor, be sure to let them know you heard them on the Meet the Doctor podcast. Check the show notes for links including the doctor's website and Instagram to learn more. Are you a doctor or do you know a doctor who'd like to be on the Meet the Doctor podcast? Book your free recording session at Meet the Doctor podcast.com. Meet the Doctor is Made with Love in Austin, Texas and is a production of The Axis, t h e a x i s.io.