Drastic or Fantastic Plastic Boob Job?

 
Fake pre-pectoral breast implants
Artificially round and hard appearing breasts after an overfilled “above the muscle” breast implant augmentation. The patient desired a more natural and smaller pair of breasts to match her frame
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
Natural result afterexchange of her overfilled implants to memory gel silicone implants “under the muscle” along with a mastopexy (breast lift).
What is wrong with this revision breast implant and lift surgery I performed? According to this patient, apparently everything!     At first, this patient came to me with ostensibly straightforward requests to “make” her breasts smaller and “better-shaped” in accordance with her body frame.  Of note, she had undergone a previous “above the muscle” breast augmentation which, in my humble opinion, left her with a net result of breasts which were too big, too round and too fake. In essence, her breasts did not lend to a pulchritudinous appearance and that is why she sought my expertise in the first place. Indeed, she wanted to get remarried after having children and was seeking “christian boobs” to attract a decent husband. So I did what any self-respecting, honest and aesthetically minded board certified plastic surgeon would do and that was to perform a capsulectomy (remove her collagenous scar capsules),  substitute her overfilled saline implants with smooth Memory Silicone Gel  implants placed “under the muscle” and conclude with a bilateral mastopexy (breast lift). I thought the surgery was an unqualified success and, further punctuated by her exceptional healing vis-à-vis scarring.     So why was she unhappy? I was thoroughly puzzled since we both had extensive discussions prior to the surgery about the usual risks, alternatives and benefits including what she exactly wanted from the surgery. I know she wanted to go smaller (check), she wanted to be natural (check), she wanted to appear more youthful and perky (check) and indeed she conceded that I did achieve these goals. However,she also expected her breasts to be firm and more round  she felt that her result was too natural, both in look and to touch and therefore something went wrong.  
Fake pre-pectoral breast implants
BEFORE: Artificially round and hard appearing breasts after an overfilled “above the muscle” breast implant augmentation. The patient desired a more natural and smaller pair of breasts to match her frame
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
AFTER:Natural result after exchange of her overfilled implants to memory gel silicone implants “under the muscle” along with a mastopexy (breast lift).
Fake pre-pectoral breast implants
BEFORE
Natural, conservative result after breast implant revision and breast lift perform simultaneously.
AFTER
                      But after further, protracted postoperative conversations with her, I realized where the disconnect was. I did not give her what she exactly wanted from the surgery because I gave her what she asked for and not what she wanted. In essence, this was a story of missed and unrealistic expectations.     More and more of these situations arise in a plastic surgery practice simply because unrealistic expectations are instilled in us 24/7 by social media. The main platforms culpable for this insidious brainwashing are the mobile apps Instagram, Snapchat and YouTube with their interminable repository of Photoshopped/FaceTuned manipulated models and instructional contouring videos. Young women come to me wanting cheekbones, buttocks or breasts like Abigail or Jocelyn Instastar simply because they are famous and therefore more popular and loved.    
Social media and Instagram star Abigail Ratchford
Social media and Instagram star Abigail Ratchford
Indeed, one patient requested Bella Hadid’s nose even though, in my opinion her rhinoplasty ended up with an “inverted V” deformity and a somewhat pinched, boxy tip. However, it did not matter to her because she considered Bella her idol andwas willing to accept a possible substandard result with potential nasal obstruction. Ah, the power of celebrity!     Recently, I had the experience of operating on another young woman who had beautifully shaped breasts with a natural cleavage. She wanted to go only slightly bigger yet have a bigger gap between her breasts. The surgery went flawlessly but the patient was dissatisfied. She agreed her breasts were fuller with a wider cleavage but she now voiced that I should have known all along she wanted her breasts to look fake, round and hard! After this perplexing conversation, I sat down and pondered the meaning of what I really do.
Social media and Instagram star, Joselyn Cano.
Social media and Instagram star, Joselyn Cano.
    It is one thing to make abnormalities such as unnatural breasts look natural but it’s  another thing altogether to make natural looking breasts look deliberately unnatural and possibly unappealing. For decades, I have endeavored to create natural results by making the deformed normal and the normal beautiful but now a new aesthetic standard has emerged in our culture and ultimately, it may not have positive consequences.   But who am I to judge?  Fake is the new real.     Randal Haworth MD, FACS

2016 State-of-the-art lip shaping-Dr. HAWORTH on the “Doctors’ show

Very few surgeons in the world understand aesthetics to the point where they can be a  true hyperaesthetic facial plastic surgeon specialist. A hyperesthetic specialist is similar to the conductor of an orchestra-he or she needs to know all the instruments better than the individual players in order to “orchestrate” them to create melodious harmony without dissonance. One of the keys to create visual harmony in the face is mastering lip rejuvenation surgery-it’s not just about adding volume (which is essentially what most practitioners and patients equate with lip enhancement), it’s about mastering the shape of both the upper and lower lip. Patients travel  from all corners of the globe to top Beverly Hills plastic surgeon and lip augmentation specialist, Dr Haworth to undergo hyperesthetic change, which may include any number of surgical art performances including a high-profile facelift, endoscopic brow lift, blepharoplasty, rhinoplasty or his lip reshaping signature surgery! https://youtu.be/cI3nEq5R3x8

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
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