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

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

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

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.
beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
A Collapsed Nasal Bridge or Saddle-Nose Deformity After a Revision Rhinoplasty Utilizing Rib Graft
beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
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 Classic Reduction Rhinoplasty

As a primary and revision rhinoplasty specialist, Dr. Randal Haworth of Beverly Hills excels with all types of complicated nose jobs, but sometimes it is a simple pleasure to be confronted with a classic reduction rhinoplasty. Though these are relatively simple in concept, all nosejobs (or rhinoplasties) must be handled with utmost care and dedication to excellence.

Why does a prospective patient consult with me requesting a nosejob?

  • Is it that their nose is asymmetrical, twisted, dented and scarred from a past rhinoplasty gone wrong?
  • Is it that their nose is too small for their face with a flat bridge and wide flat tip perhaps due to Asian heritage?
  • Is it that their nose is too wide with a bulbous tip?
  • Or is it that their nose is too big, with an associated hump, wide bones and big, drooping tip (especially when smiling)?

Well, most come to me with the latter concerns such as: “Doc, my nose is just too big for my face”, “I always hated my hump”, “My tip is falling like a bird’s beak”, etc., etc.

Upon examination, the nose will usually manifest the aforementioned undesirable characteristics to varying degrees:

  1. Is there a hump? Check
  2. Is it comprised of bone and cartilage? Check
  3. Does the nasal tip droop (with an acute angle between the upper lip and bottom of the nose/columella) especially with smiling? Check
  4. Is the nasal tip wide and/or bulbous? Check
  5. Are the nasal bones wide (where they emerge from the cheeks to form the bridge)? Check
If this common checklist is mainly affirmative, then the patient will need a classic reduction rhinoplasty. In this surgery, the tip is made narrow with either tip grafts (composed of cartilage usually invisibly harvested from the patient’s own septum), strategic suturing or both. The nasal hump is either chiseled or filed down and finally the nasal bones are narrowed by delicately in-fracturing them (“breaking the bones”). If this latter maneuver is bypassed, then an”open roof” deformity may likely arise in which the nasal bridge will look artificially flat and wide itself. Therefore the nasal bones (which comprise the sidewalls of the nose) are carefully angled inwards towards the midline in order to close the open roof which resulted from the hump removal in the first place.

Check out this patient, who underwent a classic reduction rhinoplasty on the Swan.

Here is a typical example of a classic reduction rhinoplasty,even though only subtle changes were performed. Note that a radix graft (to raise the nasal frontal angle) was placed to add  height and therefore elegance to her nose.

For a more general overview of rhinoplasty, go to:
beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
Preoperative appearance of an attractive woman seeking only refinement of her nose Postoperative results after classic rhinoplasty

The pinched nose; the rhinoplasty gone “wrong”

Everyone undergoing elective cosmetic surgery truly expects their results to be exemplary and rarely contemplate what they will do if something does not turn out as they expected. Rhinoplasty, or nose job surgery, is one of the most challenging sub specialties in aesthetic plastic surgery and Dr Randal Haworth is one of the leading specialists in revision rhinoplasty. Despite the fact that the nasal area  is generally less than 2″ x 1″ x 1 ” in  dimension, a  small amount of unpredictability always exists in terms of obtaining the “perfect result”. Of course, the more experienced and better the nasal surgeon is, the more he or she is able to harness that unpredictability and secure an excellent result.

Among the  more common complications that occur from a rhinoplasty are asymmetry, difficulty breathing, incompetent internal nasal valves (inverted  V deformity) and a pinched tip. Modern rhinoplasty techniques involve far more subtle maneuvers than old-fashioned cutting out cartilage and breaking bones.  Since the shape of the nasal tip is determined both by skin thickness and the underlying shape of the nasal cartilages, it used to be taught that to avoid a pinched nasal tip, all the surgeon has to do is avoid cutting out too much cartilage. Otherwise, the nostrils will loose the supportive function of the cartridges and collapse upon themselves thus leading to a “pinch tip” appearance.  In actuality, the situation is more complicated than that. While it is indeed important to leave enough catilage as support, modern techniques of rhinoplasty involve  delicately placing  precise  sutures in order to control the tip and projection of the nasal tip. If the knots are tied  ever so slightly tighter than normal, the supportive nature of the cartilage may be overcome by the scar tissue that will develop in the postoperative period.   The  cartilages will then become  concave in appearance thus leading to a pinched tip as seen in the accompanying photo.

Diagram showing severe nasal deformity after a previous nosejob

Preoperative nasal deformity after previous rhinoplasty. Note inverted “V” deformity, asymmetry and pinched tip

Also seen in this photo is an inverted  “V” deformity. This occurs when the  upper lateral cartridges separate away from the midline septum as well as the upper nasal bones. This results in an irregularly appearing nose along its bridge on full frontal view including an altered brow-tip curvilinear line.

Both a pinch tip and an inverted “V” deformity can result in difficulty breathing through the nose. Correction as part of a revision rhinoplasty involves carefully separating the  cartilage from the surrounding scar (which may appear deceptively similar in texture and look during surgery) and  carefully placing  precisely defined cartilage grafts on to the pre-existing weakened cartilage as support. Spreader grafts are needed to correct an inverted  “V” deformity. These are small strips of cartilage fashioned from either the septum or ear which are secured between the midline septum and the inner border of the upper lateral cartilage is-in effect, reconstructing the middle vault up the nose. If this remains uncorrected, not only does the visual deformity processed, but nasal obstruction will also occur upon inspiration. This occurs in a similar fashion to  a loose canvas roof of a tent which gets sucked in by  high mountain winds.

The postoperative photo of the same patient clearly demonstrates the correction of the pinched tip and inverted “V” deformity via cartilage placement, scar removal and  judicious fracture of the nasal bones. I also be rotated the tip in order to make the nose look “less done”.

After revision rhinoplasty by Dr Haworth, including placement of spreader and lateral crural strut grafts

To cut a long story short, added support in the  form of cartilage is needed to correct  the weakness in the form and function resulting from a rhinoplasty gone awry. Rhinoplasty is similar to a chess game. It is the only surgery  that takes me longer to perform than I did 10 years ago. This is because I recognize and  deal with any potential pitfalls that may result during the initial surgery. I have to think several steps ahead similar to a game of chess. Finally, not only do I have to make the nose look beautiful, but I have to erase all evidence that anything had been performed by a human hand. this takes time, aesthetic sensibility and patience.

This video shows how a pinched tip can be successfully repaired:

For further information about what one may expect after a rhinoplasty click here

For further information go to or call his office in Beverly Hills to schedule a consultation.