Posts Tagged ‘beverly hills nose job’

Open vs Closed Rhinoplasty in Beverly Hills

In order to perform a nose job or rhinoplasty whether in Beverly Hills, Los Angeles or wherever, the plastic surgeon must be physically able to manipulate only two things under the nasal skin-cartilages and bone, Well, the debate rages on and on as to what is the best of the two methods in gaining access to the internal cartilaginous and bony structures of the nose. The two methods are the “closed” and “open” techniques.

The “closed” technique involves creating incisions confined solely to within the actual nose (usually located just within the nostrils proper) whereas the “open” utilizes the same incisions as the “closed” but also incorporates a small additional one across the columella (the fleshy partition separating the left and right nostril at the bottom of the nose).

In this age of less invasive surgery afforded by modern technology through the use of endoscopes, modern radiology, etc. one would think that the “closed” technique represents a newer evolution in rhinoplasty surgery, but surprisingly, the opposite is true. The “closed” technique is the more traditional approach while the “open” evolved and gained in popularity as both patient and surgeons expectations grew. Perhaps unrealistically, patients increasingly expect perfection and in their quest to deliver the acme of results, surgeons need as much control as possible when performing the surgery. Control involves extremely accurate symmetrical suture placement (to reshape cartilage), hemostasis (to minimize bleeding), strategic cartilage graft location and stabilization among other factors. In order to gain the most control as possible, visibility must be maximized and this is where the “open” method far surpasses the”closed”.

Proponents of the “closed” technique cite prolonged swelling and a potentially visible scar across the columella as two distinct disadvantages to the “open”. However, in proper hands these supposed shortcomings can almost always be avoided. I, as a rhinoplasty specialist, used to perform 80% of my rhinoplasties as “closed”, but now I carry out 90% as “open” and I can safely say that over 95% of my rhinoplasty patients are delighted with their new nose by the end of the second week. If the surgery is carefully undertaken, I have seen essentially no difference in swelling between the “closed” and “open” techniques. However, the one difference I have seen are the clearly superior results afforded by the “open” method.

To see many “open” rhinoplasty results, click here and here for revision rhinoplasty.

Dr Randal Haworth can be contacted at 310 273 3000 and Is a Board Certified Plastic Surgeon (American Board of Plastic Surgery)  who practices at The Haworth Institute in Beverly Hills.

Rhinoplasty – The rib graft mafia

Over the last 3 to 4 years I, as a primary and revision rhinoplasty specialist, have noticed an increasing and disturbing trend being practiced amongst those facial and classic plastic surgeons in my immediate community of Beverly Hills and other cities. This trend revolves around the use of rib grafts for not only revision but also primary rhinoplasty (!) (or in common parlance, nose job).

A good number of rhinoplasties require cartilage in order to achieve exemplary results. Cartilage is used to either build a bridge, fill depressions, augment or support the nasal tip. It is mainly harvested from the septum (that partition that exists in the midline of the nose which separates the left and right nostril) or the ear. Though I am fully trained general surgeon and am comfortable operating in and around the lungs and heart, I rarely employ rid graft as a source of cartilage. For most, it is generally a last resort when absolutely no other cartilage source is available. Admittedly, rib provides a strong support and is generally in plentiful supply. However, a number of downsides arise when rib is harvested: a permanent visible scar is created below the breast. Additionally, significant pain can arise from the harvesting as well as a small chance of creating a pneumothorax (or a collapsed lung) . Finally, rib can be notorious for warping thereby creating a nose that is crooked.
Despite these drawbacks, I will use rib when there is a collapsed nasal septum (or dorsum creating a saddle nose deformity) or when plentiful cartilage is needed while other sources are exhausted.

See the accompanying photos.

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A Collapsed Nasal Bridge or Saddle-Nose Deformity After a Revision Rhinoplasty Utilizing Rib Graft
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A Severe Saddle-nose Deformity after Infection After Rib Graft Reconstruction
I always use cartilage to highlight and augment the nasal tip, however, when there is not enough cartilage present and I only need to build the bridge by a small amount, I do not hesitate to employ some artificial material such as Goretex®. I utilize this only when the chance of infection is remote. When patients are properly selected for utilizing Goretex®, the chance of infection extremely minimal in my experience. Unfortunately, the surgeons who habitually use rib grafts will scare the bejesus out of their patients into choosing the rib graft method by overstating the chance of infection and poor outcome if Goretex® is used.

So if I am writing that rib grafts are over utilized, then why do the rib graft cartel tell their patients otherwise?

I feel it is simply a matter of finance. When a rib graft is harvested, the surgeon can charge a lot more for both his services and the operating room, especially if insurance is billed. Most patients will not question their surgeon’s motivated choices and indeed, feel that they have no choice at all, believing that the rib-graft-mafia method is their only solution.

What is especially unsettling is that these doctors who are members of the rib graft cartel are now utilizing rib grafts for primary rhinoplasties (first time nose jobs). This is very puzzling because there is plenty of prime cartilage graft material available from the septum and ear and there is little to no reason to subject the patient to a rib surgery.

All I can say is that this is a dangerous trend which introduces unnecessary risk and morbidity to the operation.

A good patient is an educated patient and the purpose of my blog is to merely propagate information in the most objective way possible so that patients can make their own decisions as sentient adults. To learn more about primary and revision rhinoplasty , you can click here.

Dr Randal Haworth

Beverly Hills, California

The Tricky Rhinoplasty and Upper Lip Lift Combination Surgery

While many surgeons feel uncomfortable with performing an upper lip lift, let alone one simultaneously with a rhinoplasty, it can be safely done. The concern revolves around the fear of losing vital blood supply to the columella (the fleshy straight partition that exists between the nostrils), because if the blood flow is compromised to this area then necrosis or loss of the columellar skin can result. This, in turn, can lead to a possible unsightly scar. If the nose job is performed through an endonasal or closed approach ( whereby all incisions are strictly confined to within the nose itself) there should be little concern for this. However, caution must be exerted when the rhinoplasty is performed with an open technique- one that involves making a scar across the columella in order to gain better access and therefore better visualization and control of the operation. In a normal open technique the incision is placed about halfway up on the columella. Since an upper lip lift necessitates making an incision at the base of the columella (where it joins with the upper lip), the incision needed for the open rhinoplasty can also be the same one- so the incision will be used for two different purposes.

Scar placement for rhinoplasty alone and in combination with an upper lip lift

The situation becomes more complicated, however, when a persisting scar stemming from a previous open nose job is present. In this situation, the plastic surgeon must carefully plan his incisions so as not to compromise the blood supply. More often than not it is safer to keep the upper lip lift incision separate from the rhinoplasty’s in these revision cases.
The planning becomes even more critical when the nostrils need to be narrowed during the nasal aesthetic surgery ( Weir excisions). Not only does the upper lip lift need to be blended well onto the columella, but it also needs to be conformed to a freshly narrowed nasal base, with minimal undesired tension across the final scar ( which can increase the chance of it being noticeable). Intricate surgery along with an intimate knowledge of the regional anatomy and the biophysics of an upper lip lift are key ingredients to a beautiful outcome in this combination surgery. Following are two examples of before and afters of this combo surgery.

To view more upper lift results go to:http://www.drhaworth.com/procedures/upper-lower-lip-lifts/

Patient 1.Preop: 52 year old female

After Rhinoplasty with Weir excisions, Upper lip and corner Lip Lifts along with a lower V-Y plasty

Note the improved visual interplay between the nose and upper lip along with youthful tooth show and narrower oral span.

Patient 2.Preop: 35 year old. Note lack of upper tooth show and nasal tip disharmony

Postop after Rhinoplasty, upper lip lift, lower V-Y platy and lip fat transfer

Rhinoplasty Philosophy – Dr. Randal Haworth

Rhinoplasty, or what people refer to in colloquial parlance as ” nose job” surgery, is one of my favorite specialities. I have performed literally thousands of these challenging procedures as far afield as the Middle East, Europe and South East Asia. What I find so fascinating about rhinoplasty is how it can impart such dramatically positive change to the face as a whole – a classic case of the final result being greater than the sum of it’s parts. Not only do I find it immensely gratifying to invent new solutions to challenging problems, I actually like the ” feel” of the surgery- the intricate interplay between skin, cartilage and bone. Even after 16 years of private practice, I discover new, exciting nuances in techniques that the average surgeon performs without feeling. Though I considered myself “top of my game” at the time I was doing plastic surgery on ” The Swan” in 2004, I look back upon those patients today and realize I could do better on a third of those rhinoplasties I performed! Like an artist, I always aim to do better and realize that my work today is better than it was in 2004 and will be better still 5 years from now, barring some personal tragedy. The first era for me in rhinoplasty surgery was about creating beauty and my second era is about controlling beauty- imbuing a subtle softness into the result, and erasing all signs that humans hands had anything to do with the patient”s nose. A good pianists doesn’t just play the notes and chords accurately but also with crescendo and pianissimo- with feeling.
My next series of blog posts will revolve around the subject of nasal surgery and aim to share with you certain concepts, both basic and advanced, that are important to both the lay person and surgeon alike.

Dr Randal Haworth of Beverly Hills is a specialist in all forms of aesthetic plastic surgery including primary and revision rhinoplasty.For further information go to drhaworth.com

How to Minimize Risks from Nose Surgery

Rhinoplasty is a form of nose surgery aimed at improving the shape of the nose either for aesthetic or correctional reasons. While the procedure has become quite popular in modern-day society, nose jobs are still not without risks. Without the careful supervision of a professional plastic surgeon, complications such as infection, nosebleed, or a negative reaction to anesthesia may occur.

It is important to listen carefully to the surgeon’s orders before and after the operation to minimize any post-surgical risks. Reactions to anesthesia can be prevented by avoiding certain vitamins or medication before the surgery. The doctor may also advise certain guidelines on eating drinking and smoking. To prevent any scarring or permanent spot discoloration from nose surgery, careful care must be taken while washing the face after the procedure has been administered.

At The Haworth Institute located in Beverly Hills, Dr. Randal Haworth takes great care in every aesthetic surgical procedure he administers. Learn more about how to minimize the risks of plastic surgery at DrHaworth.com. Call 310-273-3000 for inquiries.