Difference between Bad Surgery and Good with a Complication.

As trifling as it may seem to the layperson, aesthetic surgery is serious business. Apart from obvious cosmetic ramifications, the seriousness becomes understandable when one considers that the surgeon must first make a healthy patient temporarily unwell in order to make he or she look better in the end. It is for this very reason plastic surgeons have an added unique responsibility which surgeons of other specialties simply do not bear. Choosing to undergo elective surgery is a series of decisions made by both the surgeon and the patient. As with all aspects of medicine, nothing is absolute, it is about controlling probability.

In this day and age, patients increasingly view plastic surgery as nothing more than a haircut with a short recovery, let alone one with a complication. Even under the best of hands, a complication can arise for any number of reasons and if it does, acting as a team with your surgeon is crucial.  Whether following a facelift, rhinoplasty or any plastic surgery for that matter, almost all complications can be fixed in the end, even if multiple surgical revisions are needed.

It is normal for the layman to consider surgical results as either “good” or “bad”,  but those adjectives can be misleading and are certainly inadequate in revealing the true story behind the result.

“Good” surgery with a complication is not the same as “bad” surgery per se. In other words, complications do not all come from “bad” surgeons and indeed, “bad” surgeons may have  successfully completed an operation without encountering obvious complications. I think it fair to say most patients consider themselves as good people and if a complication happens to them, they will perceive themselves as victims of a bad surgery and by extension, a bad surgeon. So what is the difference between “bad” surgery and a “good” surgery with a complication?

Look at it this way… in any profession, there are the “good”, the “bad” and the “excellent”. For the sake of this discussion, let’s just oversimplify the comparison between “good” and the “bad”. Since plastic surgery is as much an art (or at least an artisanal craft) as it is a science, whereby results are measured both objectively and subjectively, it is not unreasonable to compare a plastic surgeon to any artist or craftsman, including sculptors, painters and woodworkers. Artists filter their talent and vision through years of experience to not only earn but continually solidify their reputation as either being “good” or “bad”. Moreover, good artists become respected by not just producing one “good” piece but doing so consistently, whereas the “bad” consistently create sub par results as judged by the median consensus.

However, all artists, whether good or bad, are limited by the quality of material with which they work. It is known that Michelangelo’s David has been deteriorating at a far more rapid pace than would be expected because of the poor quality of its marble composition. Bernini also broke a piece of marble in half through chiseling into an unexpected vein in the stone causing him to start all over with a brand-new block. Does that make him a bad artist? Hardly not.

In other words, complications happen and that’s why there are consents to protect not only the doctor but also the patient. Consents should ensure the patients are informed as to the shared risk both they and the surgeon take when undergoing surgery.

Many complications are avoidable. Both doctors and patients must do their part to optimize a certain outcome and minimize the risk of complications. Patients must avoid certain medications that may promote bleeding, cease all smoking for optimal circulation, follow instructions and take medications as prescribed. Otherwise, surgery may be self-sabotaged. On the other hand, surgeons must do their part in educating and performing the proper operation in the right patient with skill and dedication.

Other complications are unavoidable and just because they may be explainable in hindsight does not mean they were avoidable within the context they occurred. This is why it is paramount that patients disclose all of their medical history and follow their surgeon’s instructions to a T in order to minimize unexpected situations such as abnormal bleeding, poor wound healing, etc..

What spurred me to write this particular blog was a recent experience having performed a complex revision rhinoplasty on a dear friend of mine of 20 years. Unfortunately, this advanced detailed nasal reconstruction was exacerbated by unexpected physiological conditions including excessive bleeding and poor tissue characteristics. The next day, the patient presented with so much swelling underneath the pressure cast that it was being pushed off the face. The swelling was a hematoma which I immediately evacuated from under the skin (it was 4 1/2 mL, being the largest nasal hematoma encountered by either my colleagues or myself). Accompanying this was necrosis (death) of the columellar skin (the partition separating his left and right nostrils). This was particularly disappointing to say the least because the surgical results in terms of nasal shape, symmetry, tip definition and projection were otherwise excellent. Yet losing coverage over the columella would have serious ramifications.

Despite attempts to bring vascularized tissue using local intraoral flaps, my friend eventually needed the help of a certain specialist to bring fresh tissue to the columella below the nasal tip with a temporary forehead flap.

The arrows on the drawing illustrate that portion of the nasal skin (overlying the columella) that was necrotic. Replacement is required through vascularized tissue flaps

Albeit exceedingly rare, this 1.5 x 1.2 cm skin loss was enough to eradicate not only their trust in me as a surgeon but also our long term friendship. Most patients understandably experience a spectrum of emotions including panic, sadness, denial, anger and ultimately acceptance from a complication such as this. However, nothing could prepare me for the degree of ongoing vengeful anger and hostility the patient and their partner have directed towards me including threats to go to the press and ruin my reputation.

Anger is not only destructive but also lacks focus, therefore it can be especially counterproductive to both healing and a good result (not to mention friendship!). Premature castigations of blame fuel brash, illogical decisions which actually complicate the original complication.

Understanding the differences between “bad” and “good” surgery and “good” surgery with a complication can certainly help put things in perspective. When a patient concedes the net surgical aesthetic result, at least in terms of shape and symmetry, as good if not excellent, he or she is less likely to question, and more likely trust, their original choice of surgeon. Whether their breast lift incision opened or, as in this case, a small but strategic portion of nasal skin died, the affected patient will see the “bigger picture” and believe their surgeon will  do the right thing by having their best interests at heart. This same patient understands that they were not necessarily a victim or unjustifiably punished by “bad” surgery. Instead, they will accept things for what they are, learn patience and develop a sense of optimism to set themselves up for the best possible outcome in the future.

The majority of complications concern wound healing and minor infections. For these, possible antibiotics and the “tincture of time” for healing to occur are required. Other times, simple, clinical interventions such as laser treatment, injections, the occasional scar revision and creams are all that are needed.

Other complications require more invasive solutions. Depending on the type of complication, an expeditious trip to the operatory maybe all that is required (e.g.,to drain a hematoma) whereas staged surgical revisions may be undertaken in the extremely rare case of tissue loss.

Most surgeons will recognize if a particular complication is beyond their level of expertise. A patient should not feel abandoned or simply passed off if they are referred to another expert if a complication warrants it. It is important to recognize that medicine is team work and the referral is simply a reflection of the original surgeon’s dedication to the best outcome possible.

Emotional advice after a complication

Watch out for advice with an agenda. It is understandable that if a complication does arise, fear and anxiety will prompt you to seek solace and advice from friends and family members. While this is wholeheartedly encouraged, it is important to remember that not all the advice given is good especially considering that those giving advice are not often doctors nor do they know the intricate details of the patient’s particular case. Though most advice is well-meaning in intent, some may be motivated by guilt, jealousy, personality disorders or just plain ignorance. Furthermore, the advice a patient may obtain from elsewhere may be counterproductive because it may only increase their level of anxiety.

Stay optimistic and avoid jumping to any pessimistic conclusions. It is not unheard of that acute anxiety will provoke a patient to impatiently reach for the help of an alternative plastic surgeon. Unfortunately, some plastic surgeons may be unscrupulous and advise the fragile, highly suggestible patient into unnecessary and ill-timed surgery claiming it is urgently needed to prevent some permanent deformity. Always keep a line of communication open with the original plastic surgeon to not only help allay personal fears but also be guided in the right direction with a second opinion if necessary.

“A good patient is an educated patient”-

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

Board Certified Plastic Surgeon

Beverly Hills

Self-Centered Aesthetics

After more than two decades of commitment to delivering the best of what plastic surgery can deliver in terms of aesthetic results and quality-of-life improvement, top Beverly Hills plastic surgeon, Randal Haworth, found it time to expand his philosophy into an adjacent arena. That arena is the nonsurgical approach to optimize the patient’s aesthetic wellness. Dr. Haworth has maintained that future advances in plastic surgery will not lie solely in the operatory but more in the laboratory. Specifically, advances in lasers, injectables, light and genomic therapy will take precedence over any evolutionary steps in surgical technique. Currently, non-surgical cosmetic procedures are rapidly evolving to meet the expectations, budgets and lifestyles of patients of all backgrounds and consequently, their popularity is exponentially increasing every year.

As a world-renowned expert in facial plastic surgery (including rhinoplasty, lip lifts, face lifts, eye lifts and even bodywork such as breast augmentation) Dr. Haworth has come to a point where he need not confine his artistry mainly to the syringe and scalpel but also safely and reliably imbue it into noninvasive aesthetic medicine. Consequently, he and his team at the Haworth Institute have founded Self-Centered Aesthetics, a center devoted to optimum physical appearance, through the safest, most reliable state-of-the-art technology.

Self-Centered Aesthetics (SLF-CA) will be catering to the vast majority of patients’ aesthetic needs. Among the services SLF-CA will be offering are:

1. Laser hair removal with our virtually painless Light Sheer Duet vacuum laser technology

2. Eyelash and eyebrow treatments

3. Removal of wrinkles, fine lines and sagging folds via a variety of methods including essentially all fillers, microneedling with PRP, Botox and lasers (Spectra®, Encore® Active and Deep FX™ fractionated CO2, ResurFX® fractionated erbium and IPL® Photofacial)

4. Treatment of brown spots, brown patches, red discolorations and spider veins utilizing proven laser technology (IPL® Photofacial and Spectra®)

5. Tattoo removal (Spectra® and other lasers)

6. Noninvasive body fat reduction through SculpSure®, a laser designed to achieve up to 20% fat reduction in 25 minutes with virtually no discomfort and absolutely no incisions.

7. Facial feature improvement through the selective use of fillers and Botox®. With refined aesthetic sensibility and an astute artistic sensitivity, fillers (both temporary and permanent), can enhance all aspects of the face. However, to maximize the beauty of a result without artifice or outward fakery requires customized planning to balance patients’ needs with their individual expectations. From a flat forehead with hollow temples to sunken cheeks and dark eyelid circles to thin lips and an ill-defined jawline, the professionals at SLF-CA under the auspices of Dr. Haworth dedicate themselves to make you look your very best!

​Additionally, our CENTER will offer aesthetician services to maintain and fine-tune your SELF and your AESTHETIC results. Self-Centered Aesthetics™ will be coming soon. www.selfcenteredaesthetics.com

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.

ANGELINO (2015)

Anti-aging treatments
The latest in treatments, fillers and procedures help keep you beautifully radiant-at any age. Here’s the inside track on what to do, and who to go to, to put your best self forward. Among those esteem practitioners interviewed by Angelina, Dr. Randal Haworth MD was honored to be included among them. Anti-aging treatments
scan-9“Botox plays in important role in keeping fine lines at bay”, says plastic surgeon Dr. Randal Haworth MD renowned for achieving naturally beautiful results. Haworth suggests conservative use of Botox (from $500, the Haworth Institute) in the 30s to diminish fine lines and crows feet. Beverly Hills plastic surgeon Dr. Randal Haworth MD Bellafill ($1200, The Haworth Institute) to permanently diminish deep folds and fill out eyelid hollows.