The Importance of Total Capsulectomy in Treating Breast Implant Problems.

I was exchanging breast implants and performing a capsulectomy the other day (to treat a breast encapsulation) when my anesthesia provider expressed surprise at my method. Specifically, she had commented that she has never worked with a breast implant revision specialist, especially one in Beverly Hills or California, who had removed the WHOLE collagenous capsule when treating a breast encapsulation. Apparently she has only seen plastic surgeons either make slits in  capsules (capsulotomy) or only partially remove them.  

Evidently, she was part of a growing support group of women who had their breast implants removed for mainly medical reasons and were firm believers that any associated capsules needed to be removed in their entirety during the same operation. Up to now I had no idea that performing a total capsulectomy is “a thing” and supposedly I am among a minority  who do this par for the course.

  One of the leading theories for breast encapsulation relates to bacteria and their byproduct, biofilm (a type of organic shield, if you will), surrounding the surface of the breast implant itself. One can safely assume that if a breast implant is supposedly contaminated by bacteria so is its associated surrounding capsule. Therefore, it is only logical to remove the collagen capsule in its entirety when removing or exchanging a breast implant, whether it be silicone or saline.   I created this video below to help patients better understand the vexing process of breast encapsulation and methods to treat it. Though breast augmentation​​ is one of the most popular plastic surgical procedures performed today, it is also one of the most capricious or unpredictable because breasts often times have a mind of their own and do not behave in the way we would like them to.​   Dr Haworth 2017

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

Can plastic surgery buy you happiness (especially if you are on Adderall) :)?

  “Plastic surgery won’t make you happy, but it can make you happier”

I think most sentient human beings will agree that the world it’s becoming a crazier place in which to live. We are constantly bombarded by negative imagery, negative stories, negative experiences, negative people while reminded that we are not good enough to fit the ideal as embodied by the media’s ambassadorial cadre of celebrities and certain reality stars. In more recent years, I am seeing an uptick in the amount of negative patients in my practice. I have learned to better recognize them and avoid operating on them as best I can.

Why do I do this?

The answer is simple. I avoid operating on them to better serve them . My staff and I at the Haworth Institute adhere to a basic principle of delivering the best service possible in order to maximally satisfy our patients. Yet, even if I perform the most exemplary plastic surgery and the patient is not happy with the results, then I have failed. In other words, the objective assessment of the surgical results does not match the subjective one of the patient. There are reasons for this break from reality, such as body dysmorphic syndrome and a patient’s own internal anger, discontentment, strife or call it what you will. There is much written about body dysmorphia but little is discussed about the latter situation-the angry, malcontent. Many times, these people come to a plastic surgeon seeking out surgical transformation for the wrong reasons, thinking that the surgery itself will bring a positive change in their life. When that doesn’t transpire and the patient realizes that they are still the same unhappy soul, all hell can break loose for both patient and caregiver because of unrealistic expectations. This may become a greater incendiary situation when a patient is taking Adderall or some other amphetamine-related prescription medication. Consequently, plastic surgeons should be aware of this heretofore anecdotal correlation prior to operating on anyone taking Adderall or equivalent since this may be a predictor of both disproportionate patient disappointment and anger.

I now have come up with the following saying within the last month which resonates with both my staff and myself:  “Plastic surgery will not make you happy, but it can make you happier.” In simple terms, this allows me to assess whether a patient is fundamentally happy and balanced prior to operating on them. I’m sure that there will be a few patients that still slip through the cracks, so to speak, but if I can manage to avoid operating on the majority of angry, unhappy patients then I know in my heart that I did serve them well.

Coincidently, this article just came out today about plastic surgery and happiness:

C’mon get happy! Plastic surgery can help 🙂

Dr. HAWORTH is a board-certified (American Board of Plastic Surgery) plastic surgeon located in Beverly Hills. His specialties include all aspects of aesthetic facial and breast plastic surgery, including rhinoplasty, revision rhinoplasty, facelifts, lip reshaping and breast augmentation. For further information go to drhaworth.com

What is Natural Plastic Surgery?

What is Natural?

The Challenging Question in Modern Plastic Surgery



“I am fearful about plastic surgery.  “Whenever I am in , Beverly Hills, LA or New York, I see people with bad work looking so fake.  Their lips are and breasts are so out of proportion!”

I , as a Board Certified plastic surgeon in Beverly Hills, hear this time and time again in conversation at dinner or in my clinic. “I don’t want to look like Michael Jackson!” is another common proclamation of patients during nasal surgery consultations. Instead of getting frustrated with these opinions, I agree with them. It is because I understand their source. It is simple; “good” plastic surgery is invisible, while so called “bad” plastic surgery is not.

Bad plastic surgery (whether it be a rhinoplasty, facelift or breast augmentation) can result from any of the following three scenarios. The first is poor performance of a procedure. Fortunately, this is a rare occurrence when a properly trained surgeon certified by the American Board of Plastic Surgery performs the surgery. The second is poor healing by the patient, perhaps complicated by infection. Again, this is infrequent especially in healthy, well-selected patients. Finally, the third issue is the question of aesthetic taste. No amount of plastic surgical training will guarantee appreciation of balanced facial form and pulchritude. By way of analogy, not all self-professed artists who attend the same art school will emerge as equally talented artists.

What makes for good plastic surgery then?  It is the fruit of a surgeon who’s not only technically proficient, but also possessive of a keen eye and aesthetic sense. A beautiful and youthful face reflects visual harmony between facial structures. With age, harmony turns into visual dissonance as youth cues disappear.  As a surgeon, it’s my job to serve as a conductor to bring these diverging aging elements together again. Youth cues  are lost as wrinkles, folds and sagging facial features arise. Most plastic surgical training emphasizes the re-establishment of major youth cues while overlooking the  minor ones.   In order to re create the major youth cues, I eradicate jowls; I soften the nasolabial folds, (the fatty accumulation that runs from the bottom corner of the nostril to the corner of the mouth,) contouring a strong jaw line and a firm neck and rejuvenating the eyelids through a combination of endoscopic brow lifting and blepharoplasty (eyelid tucks.)

In order to paint a convincing portrait of somebody in their youth, the surgeon should not only recreate the major youth cues, but also the minor ones. To do so, the surgeon must address the hollows underneath the eyes, the drooping corners of the mouth, the elongated upper lip (hiding the upper teeth), the sagging lower lip (exposing the lower teeth) and the elongated ear lobes. True visual choreography is required.

I’m excited by the array of minor youth cue procedures now developed. Most are relatively minimal in scope. Among these are the Endotine  ST and B mid-face lift, the first vertical and reliable mid-face lift that not only addresses the hollows under the eyes, but also softens the nasolabial folds. All in all, it provides a more natural  and subtle rejuvenation, avoiding that “pulled back” look. The procedure takes forty minutes when combined with a blepharoplasty (“eyelift” ).   This technique is made possible by the development of a new absorbable device placed via the eyelid to elevate the cheek fat pad back to it’s position of youth.

There are other minor youth cues  and I address them as well – by performing upper lip lifts with a hidden incision inside and around the nose, as well as corner lip lifts and earlobe reductions as necessary.  The upper lip lift shortens the distance between the nose and the lip, allowing the upper teeth to be seen.  One only has to peruse the fashion magazines to see how this look is indicative of a fresh and youthful lip region.

The before and after photos included below, are good examples of the above principals put to use.  This 28-year-old girl has premature signs of aging from massive weight loss. Both major and minor youth cues need to be established to achieve harmonious balance.  Consequently, I performed an endoscopic brow lift, lower blepharoplasties with fat transfer, an Endotine mid face-lift, liposuction of  the neck, upper lip lift and fat transfer.

midfacelift, browlift, blepharoplasty, upper ,lip lift, fat transfer to lips

There are artists who have become doctors and doctors who have become artists. Since I have started painting as a little child and have graduated to exhibit my later work in respected galleries, I consider myself as one of the former. I am fortunate that my background has imbued me with an artist’s eye, which translates into my work.  Regardless of Beverly Hills, New York or other urban center, Plastic surgeons should always strive to deliver to their patients not only the best technological advances in plastic surgery, but also in a way that reflects passion and inspiration with an aesthetic sensibility.

When do breast implants need to be changed?

I am frequently asked when breast implants should be “changed out” or replaced for safety’s sake. Accompanying such queries are oft paraphrased references to an article in “Allure” or similar pulp magazine (masquerading as an authority ) stating that implants should be changed every ten years. Not only is this erroneous in my opinion but also bad medicine, since such articles carelessly promote unnecessary operations. We all know that unnecessary surgery can lead to avoidable complications, but it is little known that silicone breast implants are the MOST studied medical device in the whole history of medicine!

There is basically no statistically significant evidence implicating silicone implants as causal to autoimmune disease (such as rheumatoid arthritis, lupus pr scleroderma) or any other medical conditions for that matter. Indeed, an article published in our peer-reviewed journal, Plastic and Reconstructive Surgery (vol. 114, no. 1) states that “implant rupture is a relatively harmless condition”, that does not lead to the formation of autoimmune disease.

Then why is there a continuing controversy fueled by a minor, but vocal minority? To state that this polemic is fueled by a political and not a scientific issue is an understatement.

As a testament to the times we live in, the FDA in its infinite wisdom bows down to such nonsense. The “organization” has recently vindicated silicone gel implants but only with certain caveats. The FDA recommends that patients with silicone breast implants get an expensive MRI study to detect any silicone implant leaks as early as three years after initial implantation and every other year thereafter. For what purpose, I don’t know. Modern silicone gel implants have rupture rates of less than 1% per year (based on old data) and MRI studies are quite fallible in detecting true leaks. Hence, many unnecessary and costly studies would be performed to little or no avail. Patients will foot the bills since insurance companies will rarely cover such softly-indicated exams. To add insult to injury, the FDA recommends that only women over the age of 22 are qualified to undergo breast implantation utilizing silicone gel implants.

What is the mystique surrounding the age of 22? Teens over 16 can drive cars, those over 18 can fight and kill in the armed forces (which is decidedly unhealthy in my opinion) and indeed 18 year olds can legally participate in unprotected sex in pornographic films! But are they mature enough to decide whether they can have silicone breast implants? God forbid no, according to the pious FDA! What is their reasoning behind their conclusions?

The FDA claims that women are not mature enough to decide whether they should undergo silicone breast augmentation and that their breasts are still actively changing during the late teen-to-early twenty period. We, as plastic surgeons, know that this argument holds no water since women’s breasts change throughout their lifetime! Breast enlarge and deflate with weight change, pregnancy and nursing yet the FDA thinks that placing silicone gel implants within these women (who are over 22) is fine.

I just loathe the stupid hypocrisy of all of our institutions under which we are governed. A certain Dr Thomas Wiener of Houston has written a succinct letter which he distributes to all of his patients seeking silicone breast augmentation. I have included it here for your reference.

MRI Recommmdation After Silicone Gel Breast Augmentation

1) The FDA has recommended an MRl of the breasts at three years post-op and every two years after. You are currently at one of these postoperative time frames.

2) Most sIlicone gel implant ruptures are silent. In other words, there are no symptoms. 3) MRI is not 100 percent accurate. Some intact implants wll appear ruptured, and some ruptured implants will appear intact.

This is not a fault of the radiologist or the MRl – this is the limitation of the technology.

4) Over many years of research, there is no indication that a ruptured implant will cause any disease.

5) If an MRI indicates a ruptured implant but at surgery it is found to be intact, for Allergan implants, the manufacturer’s full warranty still applies. For Mentor implants, the manufacturer will provide the implant replacement but no financial assistance.

6) You must understand that because of the limits of MRl technology, you may have surgery for an implant that is found to be intact, but you will still have undergone the possible risks and complimtions of surgery.

7) In most countries outside of the United States, the equivalent of the FDA does not recommend routine follow-up MRl.

8) The cost of the MRl is your responsibility.

Your insurance company and the implant manufacturer will not pay for this.

The decision to proceed with a postoperative MRI must be made by you, the patient, based on the above information and the information provided to you prior to surgery in the manufacturer’s FDA brochure.

The Ideal Candidates for Breast Augmentation

Women who are seeking to undergo breast augmentation basically fall into one of three categories:

1. Women who are seeking balance-these patients never had the ideal aesthetic balance between your shoulders and hips and breasts. Indeed, they always considered their breast to be underdeveloped to the point where they could never find a proper fitting bra.

2. Women who are seeking rejuvenation-this group aims to replace breast tissue which was lost to the ravages of gravity, pregnancy and nursing. Even though many members of this group often state that their breasts were perfect when they were in their early 20s, others claim that they never were well endowed at an early age. this latter subset actually are a combination of those seeking balance (1.) and those seeking rejuvenation (2.).

3. Women seeking breast enhancement to garner more attention in the sexual point of view. Although most women within this group want larger than average breasts, most still demand to have a natural, teardrop shaped and soft result that will fool even the most discriminating of observers. I do not perform breast augmentation on patients deliberately demanding a “fake” look or those wanting to achieve results bordering on the comically hideous in terms of size and shape.

All of these three aforementioned groups have legitimate reasons to undergo breast augmentation utilizing either saline or silicone gel implants. I will perform the surgery on those who have realistic expectations of what breast implant surgery can do for them as well as understand the risks of placing an implant within your body. While getting bigger breasts can enhance one’s physical appearance and perhaps even boost one’s self-confidence, it will not necessarily bring about the perfect body or change people’s perceptions or the way one will be treated.

According to Dr. Randal Haworth of The Haworth Institute, the best candidates for the aesthetic surgical procedure are healthy women with realistic expectations. People who are looking for improvement rather than perfection in the way they look, as well as those who wish to get breast implants to rectify some form of breast disfigurement.

At The Haworth Institute located at Beverly Hills, Dr. Haworth along with professional practitioners from The Beverly Hills Surgical Center and The Beverly Hills Skin Lab provides safe aesthetic and reconstructive surgical services including breast augmentation. Visit Dr.Haworth.com or call 310-273-3000 for more information.