Archive for the ‘Filler / Injectables’ Category

The Unknown Risks of Facial Dermal Fillers

In 2011, total cosmetic procedures as reported to the American Society of Plastic Surgeons have increased by 5%. While the majority of that rise has been attributed to the increasing use of noninvasive treatments which include Botox, lasers and fillers, actual surgical procedures have decreased somewhat. This may be more reflective of a rather anemic economy than an actual trend per se. Soft tissue fillers like Hyaluronic acid (Restylane®, Juvederm Ultra®, etc.), calcium hydroxyapatite (Radiesse®), and fat injections experienced some of the largest growth in the minimally-invasive market during 2011. More than 1.3 million hylauronic acid procedures were performed in 2011, up 9 percent; 286,000 calcium hydroxyapatite procedures, up 36 percent; and 68,000 fat injections, up 19 percent. However, in my practice I have noticed a shift back towards surgical procedures such as facelifts-perhaps this is because seasoned, sophisticated patients have come to realize firsthand the limitations of noninvasive treatments.

 

With the ever expanding embrace of fillers by the population, people are increasingly equating them to a manicure and pedicure. Doctors, Nurses and patients alike rarely think twice about their application and often times are not aware of their potentially serious risks. However, even a recent study has shown that seven out of 10 British doctors have experienced complications with the use of fillers (http://www.inquisitr.com/432110/wrinkles-dermal-fillers-can-cause-blue-skin-and-blindness-report/).

 

Among the fillers approved for use within the United States include many hyaluronic acids-HA (Juvéderm®, Restyane®, Perlane®, etc.), calcium hydroxyapatite (Radiesse®), PMMA (Artefill®), Sculptra® and fat. The HA’s are associated with their own unique side effects such as the Tyndall effect (a bluish gray swelling that imparts a puffy look to the lower eyes) while Radiesse®, Sculptra® and Artefill® can induce granulomas. However, all of these fillers have been associated with a few extremely rare but potentially devastating complications. Among these are skin necrosis (death of soft tissue) and vision loss. These problems result from a highly unlikely, unforeseen introduction of a minuscule amount of material into a microscopic branch of a facial blood vessel. A very small amount of filler injected into a peripheral vessel around the forehead, nose, nasolabial fold and even lip can result in these aforementioned complications. It is important to note that not only filler, but fat from a facial fat transfer and even a simple steroid injection have been implicated in both tissue and vision loss.

 

Once in the bloodstream, the filler in turn can travel downstream through the labyrinth of interconnecting blood vessels and if, in the highly unlikely event, it makes a wrong turn, it can end up in one of the blood vessels supplying the retina of the eye. Recently, I was devastated to discover that a patient of mine suffered one sided vision loss because of this very issue. Ironically, she showed no signs of external injury and still appears as a beautiful woman. A few ways for doctors to diminish the chances of such terrible occurrences are to use blunt tip cannulas instead of sharp-tipped needles whenever possible and to inject small amounts while withdrawing the syringe. Though I employ these two techniques routinely even under magnification, there is no absolute guarantee that these complications can be avoided. It is important that patients are made aware of these risks, albeit fleetingly small, in order that they can make an informed decision as to whether to proceed.

“We cannot estimate the incidence of these devastating complications among recipients to filler injections. It must be extremely rare, but it does happen,” Dr. Woo from Seoul National University’s Bundang Hospital told Medscape Medical News. The likelihood of such a devastating event is probably less than being struck by lightning

Odds of being struck by lightning in a given year (reported deaths + injuries)              1/1,000,000
Odds of being struck by lightning in a given year (estimated total deaths + injuries)      1/775,000
Odds of being struck in your lifetime (Est. 80 years)                                                           1/10,000

 

and certainly less than being injured in a car accident. Even though we are aware of the risks of driving and probably know a few people may have been seriously injured or even killed in a motor vehicle accident, few of us think twice about getting into a an automobile, turning on its ignition and driving.

A good summary of this tragic problem written from an objective standpoint can be accessed here http://www.lipostructure.com/wp-content/uploads/2012/08/Avoidence.pdf

 

 

R.D. Haworth M.D., F.A.C.S.

 

Ironically, two weeks after I wrote this blog, I was involved in a motor vehicle accident  (1 week ago, today being March 12, 2013). Fortunately, noone was seriously injured.

Brow Lift or Blepharoplasty? That is the Question

You are complaining of saggy upper eyelids.

You go to your plastic surgeon.The question is: “Brow lift or blepharoplasty? Or both?”

 

About 70% of patients coming to me requesting rejuvenation of their upper eyelids have no aging problems with their upper eyelids at all. Instead, what they are really manifesting is a pseudo excess of eyelid skin caused by a sagging of their forehead and its associated eyebrows ( brow ptosis). The skin between the eyebrows and the upper eyelashes is now compressed into folds, giving the impression age- related excess eyelid skin.
It is imperative from an aesthetic and functional standpoint that the plastic surgeon makes the correct diagnosis, differentiating brow ptosis from true excess eyelid skin. Sometimes the two conditions can coexist like in Kenny Rogers pre-surgery.

Kenny Roders Before any surgery. Note how he has a combination of heavy brows and excess eyelid skin.

Kenny Rodgers Before any surgery. Note how he has a combination of heavy brows and excess eyelid skin.

The treatment for brow ptosis is an endoscopic Browlift (which I will discuss in a future blog post and how to avoid the “surprised-look”) while that for excess eyelid skin is an upper blepharoplasty. Sometimes strategic fat transfer or filler injection above and into the brow can help reversed brow ptosis to a moderate degree.
I have seen many unfortunate results of upper eyelid surgery or blepharoplasty, stemming not from poorly performed surgery, but simply from a wrong diagnosis. In other words, the wrong surgery was correctly performed for the wrong diagnosis. I have also seen the correct surgery performed but carried out too aggressively such as in the case of Mr Rogers. If you compare his presurgical picture to the post surgical picture, one could see that his eyes are too recessed because too much fat and skin was removed.

Note the overaggressive brow lift and upper blepharoplasty leaving him with unnaturally hollow upper eyelids.

Note the overaggressive brow lift and upper blepharoplasty leaving him with unnaturally hollow upper eyelids.

Unnaturally deep recessed eyes as seen in these male celebrities can result- the upper eyes are bizarrely punched out in a feminized fashion not usually seen in nature. Yes , the upper lids are clean, but they are too sculpted and when placed adjacent to a still sagging brow, they results are just plain unattractively weird.

Wayne Newton before any plastic surgery.

Wayne Newton before any plastic surgery.

 

Wayne Newton after an overaggressive upper blepharoplasty. He probably would've been best served by a subtle brow lift alone

Wayne Newton after an overaggressive upper blepharoplasty. He probably would’ve been best served by a subtle brow lift alone

Don’t confuse this condition with people who have naturally deep set eyes such as Jeremy Irons.

Jeremy Irons has naturally deep set eyes. This is who he is and it looks completely natural.

Jeremy Irons has naturally deep set eyes. This is who he is and it looks completely natural.

Mr. Irons still has his natural character embedded in his countenance, whereas the aforementioned public figures who have had overly aggressive brow and eyelid surgery seem to had their essence extracted from their face.

 

For further information or to make a consultation with Dr. Randal Haworth, a Beverly Hills plastic surgeon and specialist in eyelid and browlift surgery,call 310 273 3000 or visit him at www.drhaworth.com.

This New Blunt-Tip Needle Screws the Bruise! Dermasculpt

What is Beverly Hills Plastic Surgeon, Dr Randal Haworth’s, latest tool to minimize bruising with injections?

Injection techniques to place filler into the face to correct lines, folds and wrinkles have became even more advanced with the use of blunt tip cannulae, such as Dermasculpt.
These are similar to needles except that they are not sharp and therefore are less prone to cut the tiny diameter blood vessels in and below the skin.

20130103-020716.jpg

What does this mean for the patient?

-Markedly less bruising
-Generally significant less discomfort
-Greater safety profile

I don’t employ them to treat all areas of the face, since certain anatomical facial features require extremely precise placement of filler not afforded by blunt tip cannulae. They are ideal to inject larger areas which require generalized plumping or filling such as the temples, cheek hollows, brows and jawline.

I have injected most types of filler through them including Juvederm, Restylane, Belotero, Artefill, Aquamid and Radiesse.

Be prepared to hear some minor crackling noise, however, for the first minute or so similar to lettuce being cut!

Fat transfer to the lower eyelid hollows/dark circles

Fat transfer is a brilliant way in order to fill up the lower eyelid circles which gradually appear with age as the mid facial fat sags southwards. Though one can inject any number of temporary and permanent fillers into the area with magnification (such as Juvederm®, Restylane®, Artefill®, Belotero®, etc.), one must remember that fat is an excellent solution. By filling out this dark circle/hollow, a smooth beautiful interface is created between the lower eyelid and the upper portion of the cheek. The harsh defining ledge of the lower bony orbit is smoothed out.

Here is a classic example of a strategic fat transfer to the lower lid. The results are permanent and natural appearing.

Note the harsh shadowing around the lower eyelid interface with her upper portion of her cheek. This is called the “tear trough” and worsens with age.

Note the smooth result that was obtained by softening the shadowing and ledge that defined her lower eyelid hollow. Fat transfer was performed in order to obtain this result.

Obviously, as we continue to age, the cheeks descends further thereby widening the “tear trough” or lower eyelid Hollow/dark circle. The fat that worked perfectly to bridge the gap is now inadequate since the gap has widened. The results of fat transfer should be permanent, however, as long as the surgeon adheres to proper fat harvest and transfer techniques.

 

For further information into how Dr. Randal Haworth of Beverly Hills(Certified by the American Board of Plastic Surgery), Call 310-273-3000

 

Rhinoplasty – “Samurai Nostrils”?

As one of the leading rhinoplasty specialists in the United States, Dr. Randal Haworth continues to challenge himself to be the best he can be. By constantly questioning his results and asking himself how he can do things better, he feels he is subjecting himself to the highest quality assurance and delivering the best possible outcomes in plastic surgery .

Performing rhinoplasties are one of my favorite specialty since the nose place such a central role in the total harmony of the face. Consider it like one of the leading instruments in the orchestra. Though most plastic surgeons and patients alike obsess on nasal humps, wide bones as well as drooping, boxy, pinched and ill-defined tips and, of course, the width of the nostrils, little attention is paid to the actual shape of the nostrils. In other words, a surgeon should not only assess whether the nostrils are wide at their base, but also whether they are arched, pointy, thick or sigmoid in shape.

One of the most common and unflattering nostril shape is that of the “samurai nostril”. Look at the following two photographs and you will see what I mean.

Seven samurai

Another example of these flared nostrils that may look appropriate as a menacing sign but not a flattering one for beautiful woman

Flared nostrils of the nose before a rhinoplasty

A samurai mask manifesting the flared, aggressive shaped nostrils that are unappealing in a woman

There are a few ways to correct this but probably the most reliable is to harvest a “composite” graft from the hidden portion of one’s ear. This detailed surgery involves insinuating this graft between an incision made on the inside of the nose, corresponding to the actual width of the retracted portion of the nostril. This graft is then sutured into place with the skin side facing the actual inside of the nostril to maintain the continuity of it’s lining. One can lower the nostril about 3 to 4 mm with this technique. Of course, some resorption of the graft occurs so it is best to over-correct this.

Other techniques involve strategic V-Y plasties, which are essentially internal tissue rearrangements of the inner aspect of the nostril in order to lower its rim, cartilage grafts in the actual substance of the nostril to help correct pinched tips while lowering the rim and, finally, filler. These latter techniques, though successful to some degree, are not as effective as an ear “composite” graft.

Note the following two cases in which “composite” grafts were taken from the ear and placed within the nostril to lower them. Of note, simultaneous upper lip lifts to further enhance a feminine appearance were performed.

Preoperative transgender patient with retracted nostrils

Transgender patient was retracted nostrils, long upper lip and droopy corners of the lip

Transgender patient after composite grafts to lower the nostril rims and an upper lip lift with DAO release

Dr. HAWORTH performed a modified rhinoplasty by lowering the nasal arched “samurai” rims (nostrils) as well as an upper lip lift and DAO release to lift up the droopy corners of the mouth

Patient with a long upper lip and retracted "Samurai"nostrils after a previous rhinoplasty

Patient with a long upper lip and retracted “Samurai”nostrils after a previous rhinoplasty by  another surgeon

Dr. Haworth performed an upper lip lit along with nostril rim lowering and fat transfer to the lips

Dr. Haworth performed an upper lip lift along with nostril rim lowering via a composite graft from the ear. Fat transfer was also performed into the upper and lower lips. Notice the more feminine harmony

 

 

 

Botox® for Depression?

Botox may soon be used to treat psychological depression. We know that it can help alleviate the symptoms of migraines in many.

Dr. Randal Haworth Beverly Hills is an expert specialist in facial plastic surgery including maintenance therapy through fillers and paralytic agents such as Botox®, Dysport® and Xeomen®.

Botulinum toxin A seems to do far more than just block the transmission of acetylcholine (the neurotransmitter chemical released from nerve endings to affect change in muscle, glands etc.).

There is new evidence to suggest that Botulinum toxin type A can be used to treat depression which was first reported in 2006 by two American doctors (Finzi E, Wasserman E “treatment of depression with botulinum toxin A: a case series, Dermatol Surg 2006; 32 (five): 645-649). Based on this small study, a much larger study with careful patient assessment has shown that a single treatment of the glabellar lines (the dreaded “11″ frown lines) with botulinum toxin resulted in a significant and sustained benefit for depressed patients (Wollmer MA, de Boer C, Kalak N, et al. “facing depression with botulinum toxin: a randomized controlled trial,” Journal of psychiatric research May 2012; 46 (five): 574-581).

Therefore, one can conclude that Botox®, through control of facial expression, seems to have the ability to control patient mood. However, is this an effect of increased self-confidence on the patient’s part or is this a result of hormone or regulatory peptide secretion as well?

Who knows at this time, but this is intriguing nonetheless. Dr. Haworth of Beverly Hills, however, is still not offering this treatment for depression even though many do say that aesthetic plastic surgery can be surgical psychiatry when performed in properly selected patients! Is this why there are so many ostensibly happy people in Beverly Hills and and its environs? ;)

For further information click on this link to body language.net

The Perfect Lower Eyelid-No Wrinkles, No Hollow Circles

 

What is the perfect lower eyelid?

We all want to have the eyelids when we were 20  with minimal-to-no wrinkles, no bags, no dark circles and a smooth transition from the lower eyelid into a nice full elevated cheekbone.

But life tends to throw us a curveball. As we get wiser, our wrinkles get proportionately deeper.

80% of this is hardwired into our genetics while 20% is in our hands. In other words, genetics is our gun and the environment is our trigger.

The best treatment is prevention by avoiding environmental toxins-tobacco smoke, harsh chemicals and sun exposure are the three main culprits that come to mind.

The second treatment is maintenance through the use of hygiene, moisturizers and strategic use of topical antioxidant therapy. Among the latter is a dizzying and bewildering array of botanicals, herbals, vitamins, roots, vegetables, nutritional supplements and berries! But the two most singularly effective treatments are the use of vitamin A (derivatives of retinol, Retin-A, etc.) and fat-soluble vitamin C. The early use of these substances goes a long way in helping to prevent and diminish the wrinkles in the first place. I know many 60+ year old patients who have virtually no crows feet (without the use of Botox™) because they have been using a derivative of Retin-A for close to 20 years.

The third and final treatment is direct physical intervention through the use of either lasers, Botox™/Xeomen™, fillers (Restylane®, Juvederm®, etc) and/or plastic surgery. Plastic surgery on the lower eyelid is called blepharoplasty and can consist of any combination of skin removal, fat bag reduction and eradicating the dark circles/hollows that frame the lower eyelid from the cheek.

As a Beverly Hills plastic surgeon dealing with the most discerning of patients, I perform lower eyelid rejuvenation every day in my practice. Any blepharoplasty specialist is well aware of the potential pitfalls of performing surgery on the lower eyelid. The most dreaded complication that patients are fearful of is a changed lower eyelid shape (that “pulled down” look that was so frequent in surgery before the 1990s).

In the vast majority of cases I do remove skin through what I call a lower lid pinch technique utilizing one single stitch. This minimizes any chance of lower eyelid retraction. This scar basically heals as an invisible one, one which needs a magnifying glass to visualize. Though I still reduce protruding fat bags on occasion, the frequency with which I do perform this has dropped precipitously in the last 10 years. In the majority of cases, transferring fat with extreme sensitivity and appreciation of the delicate eyelid anatomy, will not only significantly diminish the dark circles but also hide any protruding fat pockets around the lower eyelid.

Fat transfer, if properly performed, is by-and-large permanent around the lower eyelid and should be performed by extremely experienced plastic surgeons. While adhering to this principle, the incidence of lower eyelid irregularity and small bumps can be vastly diminished.

Oblique view of aging lower eyelid   After a lower blepharoplasty (eyelid tuck)
Wall, aging lower eyelid showing crepey lower eyelid skin, bags and mild hollowing   After a lower blepharoplasty (eyelid tuck) removing excess skin, excess protruding fat bags and performing strategic fat transfer into the lower eyelid circles (hollows)
 
An alternative view of this patient with aging lower eyelids   After a lower blepharoplasty performed by Dr. Randal Haworth in Beverly Hills
This patient has the classic signs of lower eyelid aging including excess eyelid skin with wrinkles, protruding fat bag and mild hollowing (dark circles)   After lower blepharoplasty (eyelid tuck) performed by Dr. Randal Haworth of Beverly Hills. In the surgery, he removed excess eyelid skin, reduce the excess bags of fat and performed judicious fat transfer in the dark circles

Contact The Haworth Institute for further information.

Tricky Lindsay. How Lohan is changing her looks

People seem to always ask me which celebrity did what and  why would they do that. Sometimes that is frustrating.

A close friend of mine who is a fine art photographer tells me she can always spot if someone had plastic surgery to which I reply, “No you can’t”…

That is because good plastic surgery is invisible. Therefore, by logical extension, the only plastic surgery she or anybody can recognise is visible. Most  would concur that visible plastic surgery is less ideal than invisible surgery, but this is not always the case. Think Christy Turlington and her obvious rhinoplasty as a reminder of how visible plastic surgery can elevate a face to another worldly, ethereal level and you  will get my point.

Recently Extra asked me to comment what Lindsay had done to herself based on photographs.

Dr Haworth of beverly hills is a specialist in facial plastic surgery, including  rhinoplasty, fillers and facelifts  
Lindsay Lohan in better days   Lindsay Lohan in less better but recent days

This is similar to expecting a detective to know who committed a crime based solely on showing him some iPhone photos. I can only surmise what Lindsay had done. I feel assured to say she definitely had fillers in the past (just look how her lips and cheeks have changed over the years) and a breast augmentation. But recently, the poor woman has undergone more severe change and not for the better.


She looks swollen and has an obvious “double chin”. This to me is a salient clue -

1. Is she simply bloated from substance abuse or withdrawal?

2. Has she gained weight for any number of reasons (in preparation for playing Elizabeth Taylor in Liz and Dick?)

3. Is she swollen after undergoing some involved facial surgery?

Who knows? I am simply a detective here and would need to visit the crime scene, so to speak. I would need to ask questions and perform an examination!

Dr Haworth has no profesional affiliation with Lindsay Lohan

 

Eradication of Horizontal Neck Lines


Dr Randal Haworth of Beverly Hills had discovered an incredibly effective way of diminishing those troublesome horizontal neck lines.

Only until recently has an effective method to erase horizontal neck lines or groves if you will been developed. Plastic surgeons have only offered neck lifts as a way to smooth these lines out and despite their efficacy in restoring youthful jawline and correct a “turkey neck”, they feel short in terms of treating those aging horizontal neck lines. As an alternative Botulinum toxin (Botox™, Dysport™, Xeomen™) can be injected into the platysmal bands of the neck and though it can “lift” the neck and lessen the aging cords of the neck, it does little to nothing to remove the horizontal lines.

I have found that judicious use of a filler strategically injected under magnification into the precise layer below the horizontal grooves can dramatically decrease or even erase the stubborn lines. I usually start with a temporary filler such as Juvederm™ or Radiesse™ and once the patient is satisfied, I can then graduate to a permanent filler such as Artefill™., one the former substances dissipate .

Here is a typical example of a before and after of a filler to the horizontal lines to the neck:

Horizontal Neck Lines, beverly hills nosejob, beverly hills rhinoplasty   Horizontal Neck Lines, beverly hills nosejob, beverly hills rhinoplasty
Notice moderately deep horizontal necklace lines or rings   Note the dramatic improvement of the Necklace Rings
 

The Radix Graft in Rhinoplasty

The Radix Graft

This lesser known anatomic point of the nose is often purposely overlooked by rhinoplasty specialist surgeons because of the challenges it poses to those attempting to alter it. It is represented by the angle formed by the uppermost portion of the nose as it blends into the forehead proper. Yes, altering this area does have a subtle, yet profound influence upon the final appearance of a nose job- it can differentiate an excellent result from a “so-so” one. The surgeon can raise the radix so that the nose blends into the forehead at a higher latitude as well as softly elevate the natural valley that can exist at this are if it is too deep. Furthermore, one can deepen the radix if too much bone is present between the eyeball and the bridge on profile view.

The ideal position of the radix lies approximately at the latitude of the upper eyelash/upper eyelid crease. Beverly Hills plastic surgeon, Dr Randal Haworth can raise it by placing a precisely shaped softened cartilage graft (usually harvested from the nasal septum or ear) with beveled edges onto the bone of the radix area. Alternatively the radix or nasion can be rasped or chiseled with specialized delicate instruments to a lower, deeper position.

Why does raising a radix from a low position improve the final appearance of a nose? Well, imagine two noses which are identical in shape and forward projection except that one has a low radix while the other has a high one. The one with the low radix is shorter compared to the one with the high. Now imagine two men, both with the same 34 inch waist, but one is short while the other tall. Who appears fatter? The short person does, of course. This same optical illusion applies to the nose with a low radix-it appears as it projects further out from the face as compared with the one with the higher radix and not necessarily in an attractive way.

The following photos represent a beautiful result of a corner lip lift and concomitant rhinoplasty in which the radix was raised.

beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
Note where her radix point lies. It is lower than the level of her eyelash, making the nose look more projecting than it really is. The result after a corner lip lift and a rhinoplasty with Radix enhancement.
Work here results in some extra swelling localized to the space between the eyebrows in the sense that it lasts a few days longer. Dr Haworth at the Haworth Institute has a few tricks up his sleeve to accelerate the resolution of the nasal swelling by injecting a dilute mix of Kenalog under the skin (and it is relatively painless) two weeks out. This “turbocharges” the swelling to go away!

Of course, the radix can also be augmented with a filler of some sort, such as fat, Radiesse, Juvederm, Aquamid and Artefill.