Kybella ® vs. liposuction for a double chin

While we in the cosmetic industry are getting better and better at delivering the results that patients expect, I still hold fast that 60 to 70% of modern high-tech materials and devices in plastic surgery over promise and under deliver ! Considering that the future of plastic surgery will be less about actual surgery as more more and more technological advances are made in the lab (think genetic engineering, better fillers, better lasers, etc.), this 60-70% statistic is rather disappointing. What makes this all the more egregious is the fact that doctors are forced to pay an arm and a leg for such underperforming technologies (Ulthera ® Thermage®, etc.). In light of the fact you can get a state-of-the-art Tesla  with all the bells and whistles for around $100,000, paying $150,000 or more for a machine that just delivers fuddy-duddy ultrasound technology through a wand to aid in liposuction is frankly outrageous. However, the medical tech companies can’t be solely blamed for this-they are basically governed by the FDA’s policies which, in turn, are a response to precedents extrapolated to an absurd degree by  lawyers. Unfortunately, I have seen it all too many times – a new plastic surgery technology coming out amidst a flurry of media only to fade into relatively rapid obscurity. This is similar to a Billboard chart topper only to turn out to be a one-hit wonder! In my opinion the latest overhyped snakeoil is Kybella® from the big pharma conglomerate Allergan®, proud makers of Latisse®, Botox®, Voluma®, Juvéderm®, etc. I was glad to hear from some of my esteemed colleagues at the recent American Society of Plastic Surgery meeting in Los Angeles that their thoughts on Kybella ® echoed mine.   Taking into account Kybella’s negative points, which include: 1.  relative risk of damaging important facial nerves, 2.  cost (though one treatment is less expensive than liposuction, more often than not multiple treatments are necessary and these, of course, add up), 3.  associated pain, 4.  longer recovery (which, ironically, is worse than surgical liposuction since remarkable swelling can occur after every injection session) and 5.  inferior results to those obtained  with aesthetically and skillfully performed liposuction …there is little to no advantage in utilizing Kybella® for my patients except perhaps for its superior multi-million dollar marketing campaign! Indeed, micro liposuction can provide unprecedented control in removing  fat to treat a double chin while refining the jawline and addressing the jowls as well-all with less downtime and more economically so in the end. Case in point:
Dramatic perioral rejuvenation including improvement of the jowl and chin utilizing a combination micro liposculpture and fat transfer
Dramatic perioral rejuvenation including improvement of the jowl and chin utilizing a combination micro liposculpture and fat transfer. Note the smoother jawline and submental (chin) region all performed with delicate no scar facial surgery without a face or neck lift.
Dramatic perioral rejuvenation including improvement of the jowl and chin utilizing a combination micro liposculpture and fat transfer. Note the smoother jawline and submental (chin) region all performed with delicate no scar facial surgery without a face or neck lift.
After combination micro liposculpture and fat transfer. Note the smoother jawline and submental (chin) region all performed with delicate no scar facial surgery without a face or neck lift.
After combination micro liposculpture and fat transfer. Note the smoother jawline and submental (chin) region all performed with delicate no scar facial surgery without a face or neck lift.

Know your nose job options:

Know your nose job options: knife or needle?

So you had a nose job and you don’t like the result.   Now what are you going to do?   You can always do nothing and live with the result. That’s OK. That’s your decision.   You can go back to the original surgeon or to a new one (of course, one who is board certified by the American Board of Plastic Surgery). This plastic surgeon may feel you’re a good candidate and give you two options: surgery (secondary or revision rhinoplasty) or non-surgery. In essence, the knife or the needle. Before your meeting with the plastic surgeon, you may think your only option at this point is a revision rhinoplasty with its attendant cost and recovery. However, this plastic surgeon rhinoplasty expert whom you chose to get a secondary opinion with, surprised you with his honesty, suggesting an altogether different approach to your nagging problem. He offered you a solution that involves less recovery, costs a good deal less and fixes your main concern…

  …and it doesn’t involve surgery.

  Your new plastic surgeon offered to inject filler into your nose to camouflage the irregularities, smooth and even out your bridge and even give you more of a chic tip. From the front view, by strategically injecting the filler to alter the light reflex and  control shadows your deviated nose can even be made to appear straight. He/she offers you a temporary or permanent filler. The temporary ones can serve as a dress rehearsal, so to speak, if you are unsure as to whether this is a good idea or not. Temporary ones such as hyaluronic acid  (e.g., Juvederm ®, Restylane ®, Voluma ®) or calcium hydroxyapatite (Radiesse ®)are good choices. Permanent ones such as Bellafill ®, Aquamid ® (not FDA approved) or fat transfer (a living transplant from your own body) are all excellent fillers in my opinion. You decide to go for it but you must be counseled to have realistic expectations. Fillers definitely cost less and involve less recovery (a few days of swelling and perhaps minor bruising at worst). However, the filler solution will: 1.  Neither help breathing problems 2.  Nor  will they treat all forms of aesthetic deformities such as this:
distorted medial crura of the alar cartilages
Significantly distorted medial crura of the alar cartilages
So the next time you’re considering altering the shape of your nose with a rhinoplasty of some sort, you may ask your plastic surgeon (hopefully,  board certified by the American Board of Plastic Surgery) about the filler option. Albeit,  it cannot match the power of an actual surgical rhinoplasty, the non-surgical, filler rhinoplasty can be an excellent alternative to actual scalpel- based surgery in many select circumstances. In these cases, the needle can be more powerful than the knife as one can see below:
Bellafill injectable , non-surgical rhinoplasty
This lady had a distorted nose after a previous rhinoplasty. Her cartilages were visible through her extremely thin skin and were twisted. After Bellafill ® Treatment.
Bellafill injectable , non-surgical rhinoplasty
Note the improvement of her inverted V deformity and how the nose appears straighter
OLYMPUS DIGITAL CAMERA
Note how her nasal rims have been dramatically lowered with the off-the-shelf filler. Of course, individual results may vary.

Is Yelp Contributing To Opiate Drug Addiction?

doid_yelpI recently came across this article by Jonathan Kaplan, and it struck a chord with me. The Yelp review is something that doctors have become accustomed to in recent years, but not always by choice. While Yelp can be a great way for patients to find new doctors, it also poses a lot of problems for the medical community. The care of a doctor is very different from the service you might get at a restaurant, so why would you review the two using the same system? It is much more difficult for patients to review their health care objectively. Their opinions are often based on their emotions and the pain they are feeling. In his article, Kaplan suggests that Yelp reviews might be contributing the opioid crisis in America. A patient in a great deal of discomfort may ask for more pain killers. Their doctor is trained to know the proper dosage to give them, and will often deny them anything more than what is necessary. However, more recently, patients who do not feel their pain has been sufficiently addressed have taken to Yelp to voice their anger. A bad Yelp review can really make things difficult on a practice, so more and more often, doctors find themselves giving in to these requests in order to avoid the negative reviews. I can’t count how many doctors, not just plastic surgeons, who been held hostage by their misguided patients threatening to post misleading if not blatantly false reviews if they do not get what they want. Consequently, these online reviews can be inherently biased, arising from personal agendas and not  from impartial reporting of facts. It’s not hard to imagine how this can also harm the unsuspecting public who, prompted by a malevolent post, may seek alternative treatment from a less qualified professional. This was unfortunately the case when my friends daughter was booked for a liver transplant for a congenital condition to be performed by one of the worlds preeminent liver transplant surgeons here in Los Angeles. After reading a negative online review, she canceled her surgery and ended up getting surgery elsewhere. Tragically her operation was bungled because of a negligent mismatch which resulted in her ultimate death. This could’ve been avoided if she did not read the deliberately misleading online review by the disgruntled patient (who I later came to find out was denied further Vicodin pain medication for her own good since it contains acetaminophen, a known tocsin to the liver). Like in any profession, doctors have patients that are wonderful and compliant, but they can also come across others that can be difficult to work with. The review of one difficult person should not affect an entire medical practice. Furthermore, the fear of negative reviews can not and should not lead doctors to over prescribe medication and put the health of their patients at risk.

Dr Haworth in Hollywood Reporter’s plastic surgeon list 2015

I’ve come to find out that I am included for the 2nd year in Hollywood Reporter’s top doctor list of 2015. The reason why this is such an honor is that all categories including the Plastic Surgeons’ are vetted by Castle Connolly, an independent institution specializing in such matters. In other words, no doctor can pay or influence to be included in this list. All plastic surgeons must be board-certified and are considered unparalleled in their respective fields as judged by objective monitors.
Hollywood Reporter's Best Plastic Surgeons 2015
Hollywood Reporter’s Best Plastic Surgeons 2015
It is my innate philosophy to provide the most honest and compassionate care possible while striving for aesthetic excellence which can only be achieved by sensitivity, technical precision, a critical eye and self-criticism.

Read the original article about Dr. Randal Haworth here:
Hollywood Reporter Best Doctors 2015

Shloop or Droop? How to protect your breasts 24/7

The idea of wearing a bra to bed is nothing new. I estimate approximately 6% of women already realize the benefit sleeping in a bra either because they were advised to do so by a buxom relative with ample bosom or are clever enough to understand how the laws of physics will affect their breasts in the long run. Breasts without bras BREASTS WITHOUT BRAS Breasts are affected by gravity just in the same way that Sir Isaac Newton noted that an apple is. If the apple is not prevented from dropping to the ground, it will do so and often get damaged in the process. During the day, breasts get pulled towards the earth in the same way and if no support is provided to counteract this force, breasts will eventually elongate and narrow complemented often times with downward facing nipples.

After examining thousands of breasts throughout  my 20 years of private practice, I have come to realize that those who sleep in a brassiere generally have perky breasts than those who don’t. Specifically, those who wear a bra during the day and not one at night tend to have breasts which are wider, yet flatter and concave on top with their nipples still point upwards.
Oblique cross-section of breast showing inner anatomy including Cooper's suspensory ligament's.Oblique cross-section of breast showing inner anatomy including Cooper’s suspensory ligament’s.
Apart from being blessed with good genetics to imbue your breasts with strong Cooper’s ligaments, collagen and skin there is nothing one can do to to protect your breasts from drooping except good old fashion commonsense prevention – and that comes in the form of a bra.

There is no muscle in the breasts therefore neither exercise nor yoga positions will help. There’s even poorly conceived research stating that wearing a bra creates more drooping of the breast because “they limit the growth of supporting breast tissue, leaving the breast to wither away and degrade more quickly”! In other words, they imply that the stress of gravity is good for the breast, training it like a muscle. If that were the case, patients could simply gain and lose excessive weight repeatedly in order to” train the skin” so that stretch marks can be avoided. OK…but I then wonder why pregnancy results in abdominal stretch marks…hmmmm? the-breast-7-638 My job as a plastic surgeon is to not just simply do the surgery and wish my patients all the best as they fade into the sunset. I feel it is my responsibility to also provide an “instruction manual” so to speak on how to manage their aesthetic wellness outside of my clinic and operating room.

For example, after facial surgery I recommend specialized skin care regimens and after body sculpting, certain diet and exercise. However, after breast surgery, few if any plastic surgeons recommend long term breast care except for incision/scar management, implant massage and mammograms. You only have one set of breasts and whether or not you choose to undergo plastic surgery, it is equally important to invest time and not just money in protecting their aesthetic wellness as appropriately early as you can. As soon as a young woman’s breasts are large enough to fall off the side of their chest when they are lying down is the ideal time to prevent them from doing so! In the same way that gravity exerts an affect on a woman’s breasts when she stands, it also profoundly affects them when she lies down. However, wearing a regular, daytime bra to bed simply did not provide the specialized support that was needed when on one’s back and side. When calling the support specialized, I am referring specifically to secure lateral outside support to keep the breasts from falling off to the side in addition to inner or middle support to prevent the upper breast from falling onto the lower during side sleeping. There were no bras on the market that addressed these important issues. It is for that reason that I developed NightLift ®. It had to fill three criteria: 1. First and foremost, it had to be comfortable, like a second skin if you will. Despite providing unparalleled support, no underwires exist within this bra. 2. It had to work. 48 prototypes were developed over several years to ensure ultimate support without wire or compression. We call  this technology B.U.S.T. ® (bilateral uplift support technology). 3. It has to be stylish and sexy so a woman not only feels fabulous but also looks great, whether she’s alone or with her partner. Whether a woman has undergone breast surgery or not, I recommend night list to all of my patients if she is concerned with aesthetic wellness of her breasts. After breast surgery (including breast augmentation, mastopexy or breast reduction) I fit my patients in NL a week after surgery when most swelling has dissipated. Since NL provides incredibly comfortable support without hurtful underwire, patients fall in love with this and it soon becomes a staple within their lingerie collection.   Randal Haworth MD   To learn more, go to Nightlift.com

Nostril narrowing through Weir excisions does not have to look fake

Wier excisions are very powerful tools to augment a rhinoplasty. This is a procedure that I usually perform at the conclusion of a nose job in order to refine and narrow the nostrils while controlling the flare when smiling. Most people and surgeons alike equate this procedure to simply narrowing the “floor” of the nostril by cutting out some skin but it is actually more nuanced than that. The design of the excision can be customized by changing the angulation, the position and the width of the cuts which, in turn, can change not only the dimensions but also the curvature of the actual nostril itself. A deep permanent suture is often used as well to prevent re-widening of the nostrils and reduce tension across the scar. Reducing tension across the scar as well as accurate angulation is important to achieve a nearly invisible scar. So many times I have seen obvious notching that is visible from 5 feet away and is a definite giveaway of having had a rhinoplasty. Weir excisions can be also be performed in conjunction with an upper lip lift adding to the complexity of the procedure. As a rhinoplasty and lip lift expert, I have performed hundreds of these combination techniques with excellent results. All facial plastic surgery, whether it’s primary or revisional, is challenging but taking the time to address all the details and plan them accordingly can maximize the aesthetic outcome that is not only beautiful but natural as well. The devil is in the details so to speak.
Poor rhinoplasty result with crooked , distorted tip and obvious nostril scarring after a Weir excision
Poor rhinoplasty result with crooked , distorted tip and obvious nostril scarring after a Weir excision
Again, note obvious nostril scarring from Weirs and tell-tale signs of a past rhinoplasty
Again, note obvious nostril scarring from Weirs and tell-tale signs of a past rhinoplasty
Before and after revision rhinoplasty and Weir excision as performed by Dr. RANDAL HAWORTH
Before and after revision rhinoplasty and Weir excision as performed by Dr. RANDAL HAWORTH
Primary rhinoplasty and Weir excision to narrow the nostrils in Asian patient. Note added tip projection and lack of notching
Primary rhinoplasty and Weir excision to narrow the nostrils in Asian patient. Note added tip projection and lack of notching
Primary rhinoplasty, Weir excision and concomitant upper lip lift as performed by Dr. Haworth
Primary rhinoplasty, Weir excision and concomitant upper lip lift as performed by Dr. Haworth

The Fallacy of “Stem Cell Facelifts”-the Verdict

In addition to  facial rejuvenation, buttock  and breast augmentation, stem cell marketing has reached such peaks that one may posit that they harbor the solution for global warming.

Postulated uses of stem cells
Postulated uses of stem cells
A recent study came out in our esteemed, peer-reviewed journal Plastic and Reconstructive Surgery addressing stem cell enriched fat transfer versus “regular” fat transfer  (PRS Journal: stem cell rich fat transfer). In essence, this study showed there was no difference in the effects of a fat transfer whether it was enriched with stem cells or not. This was essentially the same conclusion of a blog post I wrote a few years back. However, what makes this news different is that it comes from  a well-designed, randomized prospective study.

You may then ask yourself why are there so many doctors promoting  stem cell facelifts and fat transfers as being the chalice of youth or life’s elixir to immortality and aging. The simple answer is finance and marketing. By promoting your fat transfer as being different, labeling it with the trendy buzz prefix of “stem cell”, prospective patients will naturally think they are getting something better, longer-lasting and more natural.

You may then ask yourself why their before-and-after photos are impressive. The simple answer is that for every before-and-after photo of a stem cell-enriched fat transfer there are 10 equally-as-impressive before-and-after results from regular fat transfers. The bottom line is that one can achieve equivalent results from a regular, well-performed fat transfer-specifically, one in which the fat is appropriately harvested, cleaned and transferred by the physician with precision and artistry. Fat is basically serving as a filler, but one that is extraordinary. Extraordinary because it is not only permanent but is actually living as well-consequently it can grow or shrink depending if the patient gains or loses weight, respectively.

Stem cell embryonicStem cell science is in its infancy and we have much to learn. Indeed, many stem cell scientists now believe that the byproducts  of stem cells (cytokines, etc)  play a  far more important role in healing than the actual stem cells themselves.Fat is a rich source of stem cells but to assume that the stem cells, when transplanted into the face, can miraculously know how to uniquely reverse aging is pipe-dreaming at best.



Randal Haworth M.D., F.A.C.S.
Beverly Hills

The most obvious tell-tale sign of a facelift

Good plastic surgery is invisible but many people insist that they can always spot anyone who has had plastic surgery. For example, they claim they can always spot a celebrity with a facelift and list those with obviously sad results that garner all the press. You can refer to the three attached photographs as examples of such. (They go on to name others who have not had any plastic surgery and when I in turn correct them, they express bewildered disbelief.)
Joan Rivers with obvious plastic surgery and pixie-ear deformity
Joan Rivers with look-at-me pixie-ear deformity
 
20090328_cob_a72_8941
Bruce Jenner with a plain-as-day pixie-ear deformity after a facelift
Mickey Rourke sporting his obvious Pixie-ear and man-bun on the red carpet
Mickey Rourke sporting his obvious Pixie-ear and man-bun on the red carpet
However, this blog post is not about good plastic surgery, it is about the bad and the ugly. There are many signs that scream “facelift”:

1. Overly pulled face skin with diagonal grooves

2. Altered hairlines such as pulled-back sideburns

3. Widened, non-hair-bearing scars with step-offs in the natural hairline behind the ear

4. Distorted anatomy in front of the ear canal due to effacement of the delicate tragus cartilage and finally…

5.”Pixie ear”.

Most of these aforementioned problems stem from misplaced anchoring of the newly redraped skin flaps resulting in needlessly excessive tension across potentially visible scars. One immutable rule in plastic surgery dictates that such increased tension can create widened scars, hair loss and distorted anatomy. Yet, despite these well-documented problems, I unfortunately still see many patients who seek correction of these stigmata of ill-conceived facelifts.

Correcting these problems is not an easy task. Generally, a secondary facelift needs to be performed to release enough skin so that both scars can be removed and closure achieved in a tension-free matter. If it happens to be a lucky day, scars that were placed in front of the ear can even be moved more posteriorly to within the ear canal as in this example of a facelift I performed in order to not only make her look younger but also remove her telltale signs of past substandard surgery.

Pixie earlobe after a facelift. Note scar in front of the ear
After correction with revision facelift and tension realignment


Pixie ear deformity and tired appearance after previous facelift
Pixie ear deformity and tired appearance after previous facelift
Note correction of pixie-ear deformity after revision facelift. An endoscopic brow lift, fat transfer and upper lip lift along with a lower blepharoplasty were also performed
Note correction of pixie-ear deformity after revision facelift. An endoscopic brow lift, fat transfer, upper lip lift and a lower blepharoplasty were also performed

I don’t like comic-book butts and I cannot lie

Every ethnic group has certain predisposed notions of what ideal beauty is based upon their own genetic make up and cultural ideals. Cultural ideals are influenced by trends and therefore can change over the years (think of the beauties depicted in Ruben’s paintings). In terms of Kim Kardashian‘s genetic make up, she is partly Armenian and represents for many an ideal version of female pulchritude. Unfortunately, she is depicted on the cover of myriad top-tiered magazines as a cartoon representation of bottom-heavy female beauty and sexiness.

The cover of Paper is no exception. Here, she has been clearly “Photoshopped” to exaggerate her waist-to-hip ratio and smooth out the buttock cellulite she most certainly possesses. In this case, add oil for good measure to flame some pubescent boy’s fantasy. She may have had one or more fat transfers to accentuate her already full bottom (which may or may not show up on x-ray as microcalcifications) but, who cares?

This would all be harmless titillation were it not for the fact that many unsuspecting women will be easily influenced to attain their own version of Kim’s voluminous buttocks. Don’t get me wrong-I am the first to appreciate an hourglass figure and a well-balanced full bottom to complement a woman in-and-out of clothes. But full is different than big which in turn is different from a comic-book-big butt of a centaur.

IMG_0239.JPG

Often times buttock enhancement procedures may lead to immediate or even long-term disastrous consequences. Buttock augmentation can be performed with silicone implants, fat transfer, or injections with man-made substances ranging from PMMA to free silicone or other illicit compounds found in back alleys or mechanic shops.

Buttock augmentation with silicone implants is generally considered a safe procedure but has a higher rate of infection as compared with other implants in the body and the results often feel unnaturally hard. I perform fat transfer which is very safe but the patient must have a enough fat to transfer in order to make the result a meaningful one. I am not a proponent of injecting free silicone or other man-made substances because of their inherent danger in terms of disfigurement and possible death.

One must remember that we do not know of the long-term consequences of having such outrageously enhanced buttocks in regards to how they will look and droop as the patient ages. Drooping buttocks is a very difficult problem to treat for the plastic surgeon and the only solution would be a butt lift.

Unfortunately, most buttock lifts produce mediocre results with unsightly scars. Contrast this to a breast lift, the result of which is often spectacular with minimal scarring.

Those contemplating injections and other forms of untested ways to augment their derrière must do their homework and be prepared to roll dice. One must remember that even though one may not experience immediate complications, one must consider the long-term effects of having an extra 2 to 4 pounds of added junk in your trunk.

The trials, trade-offs and tribulations of upper lip lifts and other plastic surgery.

All plastic surgery has trade-offs.

By trade-offs, I am not referring to complications or risks.

By trade-offs I am referring to subtle and sometimes significant alterations in your appearance that will be incurred by undergoing a certain plastic surgical procedure. It is the doctor’s responsibility to inform the patient of these trade-offs (including risks of complications) while it is the patient’s responsibility to make an informed decision to proceed if he or she feels that the benefits of the surgery will outweigh the risks and trade-offs.

Examples of such trade-offs are the scars in and around the ear that result from a facelift. Even though they may be near invisible, they are scars nonetheless. The majority of patients feel that benefits of the facelift outweighed any of the associated trade-offs. Similarly, patients who undergo an abdominoplasty (tummy tuck), mastopexy (breast lift) or brachioplasty (arm lift) should be fully aware that they will develop scars from those procedures. Though the majority will heal well with very acceptable scars, most of the time the scars will be visible to some degree.

Patients who undergo a rhinoplasty must understand that their nose will be numb, stiff and hard for up to 3 months or more while swelling can persist for 1 to 2 years. Numbness from a facelift or a browlift can last many months as well. Despite understanding these trade-offs, the vast majority of patients have no problem undergoing these procedures once they have decided to do so.

Over the years, I have found it curious that a small minority of patients undergoing lip reshaping surgery in the form of upper lip lifts and V-Y plasties had unrealistic expectations in terms of their healing and results. They were surprised even angry that they experienced numbness, stiffness and associated scarring. Sometimes a very subtle change in the nostril position occurred after the surgery. These trade-offs may arise even though the result of the upper lip lift is successful from the aesthetic standpoint-in other words, the net benefit in the sensual-youthful-beauty quotient for the face has been increased. However, a few may consider the lip lift a failure if they have experienced even a slight degree in any of these trade-offs.

Though these trade-offs can mostly be successfully reversed, a patient should not elect to undergo such a procedure if he or she will not accept that these can be normal aspects of the procedure. If one thinks about it, an upper lip lift will have its trade-offs in the same way other procedures would have their own yet it perhaps gets more attention than other anatomical features of the face because the lips are expected to not only look beautiful but also function as well.

And function they do, more than any other part of the face. Indeed, lips are used to express, emote, eat, kiss and speak-essentially they move millions of times a day! Because of these strong repetitive muscle forces around the nasal and oral region the plastic surgeon must create a strong upper lip lift that will resist these forces in order to achieve a result that is long-lasting, with minimal scarring and nasal distortion.

In fact, lip shaping procedures are the most challenging of all facial plastic surgeries, even rhinoplasties. Though the success of facelifts are measured in centimeters, brow lifts in increments of 2 to 4 mm and rhinoplasties in millimeters, lip reshaping surgery is measured in quarter-to-an-eighth of a millimeter! With those scales, one can almost consider this close to microsurgery.

In 2014, it would be a miracle to undergo an upper lip lift with an unequivocal guarantee of no scarring, nasal distortion, prolonged minor sensory changes and stiffness. If you are contemplating undergoing an upper lip lift but will not tolerate any of these tradeoffs, I suggest you avoid the procedure altogether and wait for that miracle to happen.
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