Beautiful Upper Lip Lifts without scars?

When we choose to undergo a plastic surgical procedure, we do so to get a beautiful result which is balanced for the face and one that is as permanent as possible and one which doesn’t interfere with function. I don’t think anyone would argue with the above. Lips are a unique anatomical future. They connote youth, beauty and sexuality. However, their job is not only to look beautiful, they have to also function. This is contrast to a nose or an ear which have no moving parts. And as a plastic surgeon helping to advance the field of lip reshaping surgery (LRS), this is where the challenge lays. When a patient asks me to make them a beautiful set of lips, I have to ensure:
  • a. A beautiful upper lip
  • b. A beautiful lower lip
  • c. Both upper and lower lips harmonize with each other
  • d. The harmonizing upper and lower lips harmonize with the surrounding face in terms of shape and scale (volume)
  • e. The upper and lower lips continue to harmonize well into the future (akin to a long-lasting result)
  • f. Scars are as imperceptible as they can be
  • g. The chance of nasal distortion and other complications are kept to a bare minimum
  • h. Lip function is retained (perhaps even improved with the new found confidence!)
  • i. Recovery is minimized whenever possible
  • j. A patient’s expectations are aligned with reality.
(Of course, “j.” should be at the top of the list. If a patient has unrealistic expectations, then no matter how successful a surgery is, if a patient in the end is dissatisfied, the surgery is a failure to them). One of the cornerstones of lip reshaping surgery is the upper lip lift. Most of us appreciate that beauty is mostly conferred through shape and less so by colour and volume. The lips are no exception. An upper lip that is considered beautiful on a primal, instinctual level is one comprised of a short nose-to-lip distance, a beautiful “O” arch, a visible vermilion balanced with the size of the lower and, of course, an appropriate upper tooth exposure. Sexy After performing thousands of upper, corner and lower lip lifts, the secret to unparalleled longevity and a naturally beautiful lip shape is stability. One must understand that, like the hands, the lips move hundreds of thousands of times a day- eating, talking, expressing and other things that shall go unmentioned in this post. Therefore, for an upper lip lift to be successful in terms of beauty and longevity, it should not only resist the downward pull of gravity but also be stabilized against everyday movement (which contributes to re-stretching of the lip, obvious wide scarring and downward pull on the nose). The OOS (Orbicularis Oris Suspension) superficial muscle technique provides this very stabilization by anchoring the superficial layer of Orbicularis Oris just below the dermis to the periosteum (or lining of the bone) below the nose. (The Orbicularis Oris is the circumferential, sphincter muscle that surrounds the oral aperture). By stabilizing the lip in two directions bilaterally I am able to customize the curl and expression of the upper lip to make it not only youthful but sensual as well. The two direction approach is analogous to the way a marionette can come to life by the hands and strings which control it. The skin-only lip lift is a far simpler operation to perform and solely involves removing skin and sewing the skin edge of the lip to that of the bottom of the nose. The only thing holding the skin-only lip lift in position are the dissolvable stitches in the dermis which are no match against constant daily mouth movement and gravity’s pull. As a result, there is a far greater likelihood of the nostrils being pulled downwards, obvious scarring, significantly decreased longevity and suboptimal aesthetics.
After a "modified "upper lip lift
After a “modified “upper lip lift by another Beverly Hills Plastic surgeon, which is basically a skin-only lip lift marketed as something other than it really is. Note severe right nostril pulldown with bizarre pleat along with an “A frame” deformity and an exacerbation of her downward slanting can’t of her upper lips.
I can personally attest to the dramatically decreased longevity, unremarkable results, worse scarring and nasal distortion from the thousand or so skin-only lip lifts I performed in the 90s. Though the skin-only  recovery is easier, the current version of the OOS upper lip lift may allow the patient to appreciate results as early as 10 days. Not only does the OOS technique shorten the distance between the nose and lip but it also allows upper tooth show( that goes without saying really), subtle added rollout of the upper lip’s pink vermilion, welcomed narrowing of the aperture of the mouth (that gets wider with age) and even noticeable reduction in the nasolabial folds. Contrary to some misperceptions, no muscle is removed and no cases of permanent numbness or any paralysis ever encountered.
After an OOS upper lip lift by Dr Haworth. Note minimal scar and no nostril descent
Upper lip lift enhancement
After an OOS upper lip lift by Dr Haworth. Note minimal scar and no nostril descent
More and more people are realizing that the upper lip lift( and other LRS techniques) may play as important a role as a facelift and eyelid surgery in facial rejuvenation. Choosing proper techniques, performing them well and understanding how all elements of the lip work together can be the ultimate magic trick to transform a face from “Meh to Mwah”! Dr Haworth July 2018

Self-Centered Aesthetics™

Embracing Artistry

By Inga Hansen

Photography by Cory Sorensen

Plastic surgeon Randal Haworth, MD, is taking the next step in his career with the launch of a stylish, comprehensive aesthetic care facility.

Randal Haworth, MD, made a name for himself in aesthetics in the early 2000s when he joined Fox television’s reality show, “The Swan.” On the program, he was part of a team of plastic surgeons, stylists and makeup artists who dramatically transformed participants’ appearances, Earlier this year, he transformed his own Beverly Hills, California-based practice when he moved to a new, custom-designed facility that incorporates a full range of aesthetic services—from facials and nutritional services to fillers, lasers and surgical procedures.

Dr. Haworth’s design philosophy for the new Haworth Institute was nature meets high-tech.

“It’s a beautiful place, and all our services are under one roof—the surgical center, my clinic and our new noninvasive center, Self Centered Aesthetics,” says Dr. Haworth. “Patients always asked us, ‘What else can you do?’ ‘How do I maintain this?’ It just doesn’t make sense nowadays not to offer the full-range of aesthetic treatments.”

In addition to laser treatments and injectables performed by Dr. Haworth and his R.N., celebrity esthetician John Tew performs signature facials and naturopathic doctor Matea Polisoto, who goes by “Dr. Matea,” offers IV therapy and nutrition counseling. “Like John, she has a very big following in Beverly Hills and beyond,” says Dr. Haworth. “She is involved with IV therapy, which helps augment the pre- and postoperative surgical experience, and optimizes healing.

“The people working with me are just as important as the surgeon—it’s all about having a team,” he says.

The Frustrated Artist

Born in Los Angeles and educated in England, Dr. Haworth has a somewhat unusual background for a Beverly Hills plastic surgeon. “My dad was English and spent World War Il in London selling bootleg whiskey during the Blitzkrieg. My mother and her family lived in Holland during the German occupation,” he says.

Following the war, both of his parents immigrated to the United States seeking opportunities, of which there were few in post-war Europe. “They met, and I was born in Los Angeles. But my dad always wanted me to be in England eventually,” says Dr. Haworth.

When he was 9 years old, he and his parents drove to Central America and boarded a cargo ship to England. During his school years in London, Dr. Haworth became enamored with the arts. “l always drew—and I was very good at a young age. In University I joined band. I was really into the arts, and that’s what I wanted to pursue,” he says. “But my parents, being war babies, wanted a doctor in the family and I was their only child.”

During a road trip prior to his final year at the university, he shared his goals with his parents. “We were in a VW bus and they said, ‘We’ll disown you if you become an artist. Make your decision’—it was really bizarre,” he says. His mind flashed back to a BBC interview of Kurt Wagner, MD, he had seen when he was 13. “l said, ‘Then I’ll be a plastic surgeon,’ having no idea what was involved in that.”

He came back to the U.S. and enrolled in medical school at the University of Southern California. Following graduation, he completed a five-year general surgery residency at Cornell Medical Center in New York. Dr. Haworth made his way back to the West coast for his plastic surgery residency at the University of California, Los Angeles.

“After my residency, I had no money so I was anxious to go into practice. I thought, well then I have to goto Beverly Hills because that’s where successful plastic surgeons go,” he says.

Another surgeon offered to rent him a space in his clinic’s kitchen, which was housed in one of the most desirable medical buildings in Beverly Hills. “He had a little pocket door in front of the kitchen so I stayed in there,” says Dr. Haworth. “During my clinic days, I would take his diplomas off the walls in the two little exam rooms and put mine up, and that’s how it started.

“l look back fondly on those days now, but it was horrible at the time. If I had two surgeries in a month, it was a great month.

Finding His Niche

During his UCLA residency, Dr. Haworth won a plastic surgery research prize for his lip surgeries, which provided a unique niche with which to build his practice, More than 20 years later, he has patients from all over the world who travel to the Haworth Institute for their lip surgeries.

“You can be the best doctor in the world, but if you don’t have marketing, no one will know about you,” he says. “So I leveraged that award and started getting known for lips, even though my favorite surgeries are noses, mid- facelifts and what I call hyperaesthetic surgeries where we change everything. The lips are what I was known for, and now I get jazzed by that because there’s really no competi- tion in the world for these surgeries.”

He offers upper, lower and corner lip lifting procedures as well fat transfer and F.A.T.M.A. (fat transfer & mucosal advancement). “l do many types of lip lifts because it is shape before volume; there are many things that fillers alone cannot do,” he says.

Embracing and Investigating New Technologies

Despite the limitations of traditional filling techniques, Dr. Haworth has embraced dermal fillers as effective tools to perfect his patients’ lips. In some cases the new, less invasive procedures are even surpassing what he can achieve in the O.R.

“Our mouths get wider as we age and our lower teeth become visible,” he says. “People will often just fill the lower lip horizontally, which won’t help with these concerns.”

In his surgical center, he performs lower lip V-Y plasty procedures to narrow the mouth, lift the bottom lip and pout out the middle third of the lower lip. But, due to the minimal improvement, he recently became interested in the idea of using vertical filler injections to lift and shape the lower lip.

“About three months ago, I started injecting vertically into the lower lip. I place my long cannula or a long needle vertically from the bottom of the prejowl sulcus all the way to where I see the needle blanching on the vermillion on the back of the lower lip on the sides. Then I inject vertically as I pull the needle out,” he says. “l am seeing such dramatic elevation of not just the lower lip but the whole corner of the mouth—the marionette folds are dramatically reduced and the labiomental sulcus opens up.”

He is calling this the Caisson technique after Caisson beams in construction. “The patients are three months out now, and the results are far better than what we see with the lower V-Y plasty in hiding the lower teeth,” he says.

Dr. Haworth is investigating new ways to augment and lift lips using dermal fillers.

“l love doing surgery, but plastic surgery is in some ways a dying field,” he continues. “The future of plastic surgery lies in the lab, not the operating room. Eventually they are going to know how to stop senescence. In the meantime, the future of aesthetics is laying more and more in lasers and newer, better fillers, and I want to stay on the forefront of that.”

His biggest challenge is determining which new technologies and procedures live up to the hype—and resisting the urge to bring in every new device about which patients inquire. “Sixty to seventy percent of all new medical cosmetic technologies overpromise and under deliver,” he says. “First it’s a big ‘Wow!’ Then results are ‘operator-dependent,’ then it’s gathering dust, so I vet all these technologies and only offer the ones I believe are proven to work.

“What I want to offer my patients with the Haworth Institute and Self Centered Aesthetics is more than one-stop aesthetics, It’s the tools and knowledge to deliver the absolute best treatments for their individual concerns and lifestyles,” continues Dr. Haworth. “We have a turbocharged armamentarium of proven noninvasive treatments to carry on the philosophy that I espouse in my surgeries, which is really detailed aesthetic work.”

Self-Centered Aesthetics

Recently, I was honored to be featured on the cover of the highly popular regarded trade magazine of the noninvasive aesthetic industry, MedEsthetics. Here is the article. We at Self-Centered Aesthetics ™are super excited to be off to such a great, auspicious start. We are aiming to deliver the best, state of the art noninvasive treatment to all patients, under one roof with my philosophy of beauty. Embracing Artistry By Inga Hansen Photography by Cory Sorensen Plastic surgeon Randal Haworth, MD, is taking the next step in his career with the launch of a stylish, comprehensive aesthetic care facility. Randal Haworth, MD, made a name for himself in aesthetics in the early 2000s when he joined Fox television’s reality show, “The Swan.” On the program, he was part of a team of plastic surgeons, stylists and makeup artists who dramatically transformed participants’ appearances, Earlier this year, he transformed his own Beverly Hills, California-based practice when he moved to a new, custom-designed facility that incorporates a full range of aesthetic services—from facials and nutritional services to fillers, lasers and surgical procedures. Dr. Haworth’s design philosophy for the new Haworth Institute was nature meets high-tech. “It’s a beautiful place, and all our services are under one roof—the surgical center, my clinic and our new noninvasive center, Self Centered Aesthetics,” says Dr. Haworth. “Patients always asked us, ‘What else can you do?’ ‘How do I maintain this?’ It just doesn’t make sense nowadays not to offer the full-range of aesthetic treatments.” In addition to laser treatments and injectables performed by Dr. Haworth and his R.N., celebrity esthetician John Tew performs signature facials and naturopathic doctor Matea Polisoto, who goes by “Dr. Matea,” offers IV therapy and nutrition counseling. “Like John, she has a very big following in Beverly Hills and beyond,” says Dr. Haworth. “She is involved with IV therapy, which helps augment the pre- and postoperative surgical experience, and optimizes healing. “The people working with me are just as important as the surgeon—it’s all about having a team,” he says. The Frustrated Artist Born in Los Angeles and educated in England, Dr. Haworth has a somewhat unusual background for a Beverly Hills plastic surgeon. “My dad was English and spent World War Il in London selling bootleg whiskey during the Blitzkrieg. My mother and her family lived in Holland during the German occupation,” he says. Following the war, both of his parents immigrated to the United States seeking opportunities, of which there were few in post-war Europe. “They met, and I was born in Los Angeles. But my dad always wanted me to be in England eventually,” says Dr. Haworth. When he was 9 years old, he and his parents drove to Central America and boarded a cargo ship to England. During his school years in London, Dr. Haworth became enamored with the arts. “l always drew—and I was very good at a young age. In University I joined band. I was really into the arts, and that’s what I wanted to pursue,” he says. “But my parents, being war babies, wanted a doctor in the family and I was their only child.” During a road trip prior to his final year at the university, he shared his goals with his parents. “We were in a VW bus and they said, ‘We’ll disown you if you become an artist. Make your decision’—it was really bizarre,” he says. His mind flashed back to a BBC interview of Kurt Wagner, MD, he had seen when he was 13. “l said, ‘Then I’ll be a plastic surgeon,’ having no idea what was involved in that.” He came back to the U.S. and enrolled in medical school at the University of Southern California. Following graduation, he completed a five-year general surgery residency at Cornell Medical Center in New York. Dr. Haworth made his way back to the West coast for his plastic surgery residency at the University of California, Los Angeles. “After my residency, I had no money so I was anxious to go into practice. I thought, well then I have to goto Beverly Hills because that’s where successful plastic surgeons go,” he says. Another surgeon offered to rent him a space in his clinic’s kitchen, which was housed in one of the most desirable medical buildings in Beverly Hills. “He had a little pocket door in front of the kitchen so I stayed in there,” says Dr. Haworth. “During my clinic days, I would take his diplomas off the walls in the two little exam rooms and put mine up, and that’s how it started. “l look back fondly on those days now, but it was horrible at the time. If I had two surgeries in a month, it was a great month,” he says. Finding His Niche During his UCLA residency, Dr. Haworth won a plastic surgery research prize for his lip surgeries, which provided a unique niche with which to build his practice, More than 20 years later, he has patients from all over the world who travel to the Haworth Institute for their lip surgeries. “You can be the best doctor in the world, but if you don’t have marketing, no one will know about you,” he says. “So I leveraged that award and started getting known for lips, even though my favorite surgeries are noses, mid- facelifts and what I call hyperaesthetic surgeries where we change everything. The lips are what I was known for, and now I get jazzed by that because there’s really no competi- tion in the world for these surgeries.” He offers upper, lower and corner lip lifting procedures as well fat transfer and F.A.T.M.A. (fat transfer & mucosal advancement). “l do many types of lip lifts because it is shape before volume; there are many things that fillers alone cannot do,” he says. Embracing and Investigating New TechnologiesDespite the limitations of traditional filling techniques, Dr. Haworth has embraced dermal fillers as effective tools to perfect his patients’ lips. In some cases the new, less invasive procedures are even surpassing what he can achieve in the O.R.”Our mouths get wider as we age and our lower teeth become visible,” he says. “People will often just fill the lower lip horizontally, which won’t help with these concerns.”In his surgical center, he performs lower lip V-Y plasty procedures to narrow the mouth, lift the bottom lip and pout out the middle third of the lower lip. But, due to the minimal improvement, he recently became interested in the idea of using vertical filler injections to lift and shape the lower lip.”About three months ago, I started injecting vertically into the lower lip. I place my long cannula or a long needle vertically from the bottom of the prejowl sulcus all the way to where I see the needle blanching on the vermillion on the back of the lower lip on the sides. Then I inject vertically as I pull the needle out,” he says. “l am seeing such dramatic elevation of not just the lower lip but the whole corner of the mouth—the marionette folds are dramatically reduced and the labiomental sulcus opens up.”He is calling this the Caisson technique after Caisson beams in construction. “The patients are three months out now, and the results are far better than what we see with the lower V-Y plasty in hiding the lower teeth,” he says.Dr. Haworth is investigating new ways to augment and lift lips using dermal fillers.”l love doing surgery, but plastic surgery is in some ways a dying field,” he continues. “The future of plastic surgery lies in the lab, not the operating room. Eventually they are going to know how to stop senescence. In the meantime, the future of aesthetics is laying more and more in lasers and newer, better fillers, and I want to stay on the forefront of that.”His biggest challenge is determining which new technologies and procedures live up to the hype—and resisting the urge to bring in every new device about which patients inquire. “Sixty to seventy percent of all new medical cosmetic technologies overpromise and under deliver,” he says. “First, it’s a big ‘Wow!’ Then results are ‘operator-dependent,’ then it’s gathering dust, so I vet all these technologies and only offer the ones I believe are proven to work.”What I want to offer my patients with the Haworth Institute and Self Centered Aesthetics is more than one-stop aesthetics, It’s the tools and knowledge to deliver the absolute best treatments for their individual concerns and lifestyles,” continues Dr. Haworth. “We have a turbocharged armamentarium of proven noninvasive treatments to carry on the philosophy that I espouse in my surgeries, which is really detailed aesthetic work.”

Gloria (Croatia) 2017

Dr. HAWORTH is interviewed by Gloria magazine about his life in being a top Beverly Hills plastic surgeon and catering to the aesthetic whims and desires of the rich and famous as well as his charity work. He has heard about Gloria magazine from his ex wife who was Serbian Actress Ana Alexander (Stojanovic).

The Unique Vision behind The Haworth Institute

Dr Randal Haworth’s Artisitic 1800 lb Reception Counter
Art and Plastic Surgery
Dr Randal Haworth’s Artisitic 1800 lb Reception Counter
Art and Plastic Surgery
Dr Randal Haworth’s Artisitic 1800 lb Reception Counter
art and Plastic Surgery
Dr Randal Haworth’s Artisitic 1800 lb Reception Counter
Realizing a vision in stone Swapping his scalpel for a chisel, Beverly Hills plastic surgeon Dr. Randal Haworth MD was hands on in the design and construction ofhis new ojj‘ice lobby, which included a mammoth reception counter made from Carrara marble by lenniter Richinelli When designing his new office for his plastic surgery practice in Beverly llills, CA, Dr. Randal llaworth MD was drawn to while marble In create the look he envisioned. ntients visiting the office of I)renowned plastic surgeon Dr. Randal Haworth MD in Beverly Hills, CA, will observe firsthand the doctor’s flare for design. As the former Chief Resident in Plastic and Renonstructive Surgery at the UCLA Medical Center and recipient of the title of “Plastic Surgical Consultant Of The Year for 1993-94,” I-laworth excelled in science and medicine, but always remained in touch with his artistic side. As a result, it was no surprise how intimately involved he became in the design and construction of his new office space, which features an extensive amount of stone. “My inspiration for the lobby was simply the notion of lime,” explained Randal. “Amongst the seemingly infi- nite number of both inorganic and 66 August Z01? | Stone World For the lobby walls, an alternating formation of both protruding and recessed multi-tiled pieces was individually assembled in sections from a 1-are and now unavailable source of distressed unfinished 2- x 8-inch marble tile veneer. organic ‘things’ on this planet, only the human being can be affected psychologically by the idea of time passing. Of course, everything on this planet, including those entities we consider permanent, such as the mountains, oceans and atmosphere, physically change over time. However, it is only the human who can be con- sciously aifectecl by the concept of time and consequently react to the present and plan for the future. “‘l‘he bmwn, white and gray palette, including the dual-toned aqua and cobalt blue sofa, reflects the basic molecular foundation of Mother Earth herself, while the repetitive pattern formalired by the textured shone walls represents what is ostensibly immuta- ble and ‘forever/” Haworth went on to say. “ln contradisfincfion to this is the massive 18-foot-long marble reception counter, which is transformed from violent, yet beautiful chaos, into a tra- ditionally refined smooth surface. As a metaphor of how modern plastic sur- gery can make unappealing forms into beautiful ones, the sculptural transfor- mation reminds us we can change how we appear over time.” The doctor explained how he has always been attracted to all types of stone construction since he was a child attending the King’s School in Canterbury, England, which he said is purportedly the oldest school in the world. “Many of the classrooms and dorms were based within ancient Gothic stone buildings surround- ing the 1,400-year-old Canterbury Cathedral, so for me, stone represented stability, strength and wisdom. Stone is far more than just a construction mate- rial — within its austerity lies timeless beauty,” he said. The lobby walls consist of an alter- nating formation of both protruding and recessed multi-tiled pieces – totaling 120 square feet “l had each tile section individually assembled from a rare and now unavailable source of distressed unfinished 2- x B-inch mar- ble tile veneer that came in old wood crates from Italy,” said Haworth. “The oombinal-ion of the particular texture — along with the pattern and manner in which it was assembled – was chosen to maximize depth.” The showpiece of the 240-square- foot office lobby is the mammoth reception desk made from two massive slabs of Carrara marble. These were divided into nine pieces in order to complement the full 18-foot length of the counter. “The stone materials were chosen from both an aesthetic and practical standpoint,” explained Randal. “I was looking for a white purity for the wall themselves, while the slabs for the reception counter were chosen for a certain multi-variegated pattern, as well as thickness. The thickness was needed to accommodate both violent carving and impart mass in the end.” The stone was supplied by Empire Marble in San Fernando Valley, CA. The installation When it came to the stone installa- tion, Randal was intimately with the 1-ton reception “Indeed, I rolled up my involved counter. sleeves to carve and polish the structure and ulti- mately camouflage its seams because, it turned out, l was the only one who knew what I envisioned,” he explained. “l experimented with a number of painterly techniques in order to visu- ally unlfy the individual sections of marble as one horizontal massive rock. For the foundation, a pony wall was set up as the main anchoring frame span- ning frorn the left corner adjoining the tiled wall to the right suspended hand- icap accessible section. Creating and anchoring the recep- tion desk was a trial-and-error process, explained l-laworth. “As experienced and proficient as they were in their craft, I realized my team was inad- equately prepared for what I wanted Stone World | August 2017 67 The Carrara marble slabs were cut into nine pieces and then assembled to create the mammoth reception counter. ‘Work was then dune ho smooth out the seams. The main attraction of the office lobby is an 18 -toot-long reception counter made tram two massive slabs of Carrara marble. to create,” he said. “It was basically my fault because my inexperience did not allow me to realize theirs in han- dling this one idiosyncratic aspect of the total project. It was as much about structural engineering as it was about art. I realized that when you are utiliz- ing others to translate your vision of something that is unique and out of their comfort zone, you must seek top specialists in that particular medium you want to work with. For example, despite the innumerable conversations and detailed drawings I provided to the architect, project manager. engi- neer and marble craftsman, the form of the counter during construction began to differ widely from what I was envi- sioning. lt was fortunate that l arrived after surgery just in time before the glue and mortar dried so that I was able to have the nine stone pieces repo- sitioned to my “ln a similar vein, the person l commissioned to do the carving was woefully oft course in terms of ele- gantly decreasing the texture of the marble from left to right to convey the analogy from chaos to perfection,” Haworth went on to say. “With dead- lines rapidly looming, I realized that I had to take matters in my own hands to become quickly proficient with the Makita saw, power sanding and the plain old chisel and mallet until the wee hours of the night.” While there were some bumps in the road during construction, Randal was pleased with the final outcome. “Since wehavernovedintoournew officeore and half years ago, the subjective raw emotional feelings as an artist during the act of creation have now dissipat- ed,” he said. “I am affected by it in in a more objective way. lam amazed that I created what I feel is a magical, mod- ern yet spiritual space which brings an element of strength and peace that will not vanish with time. Marble since CrecoRoman times has fascinated humans, as evidenced in temples nest- ing our desire of eternity. Design today still wants to echo the perpetual against nature’s backdrop. Yet, nature will always be ahead of us in our creative search which can only be successful if we understand and respect nature before we attempt to perfect it.” El 68 August 2017 I Stone World

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

Follow up: Kim is the Butt of the Jokes

Well… as I originally predicted in a blog post at the time Kim Kardashian’s champagne-glass-bottom graced the cover of Paper magazine, there would be “fall out” to the story. Judging by active reaction to recent un-retouched photographs of Kim’s derrière in the media by both fellow plastic surgeons and public alike, comments have generally been less than flattering. 
Fortunate aftermath of wanton Buttock enlargement without consideration of body proportions and pulchritude
My blog post was essentially a warning to those seeking to “maxi-size” their assets in response to media’s insidiously pervasive influence on the public’s impressionable collective psyche.  A copy of my original blog post is here:
I don’t like comic book butts and I cannot lie
Not to say that the images in question expose overtly ireversible droop of Kim’s buttocks, they do unquestionably reveal the dimpling, pitting and bulging of exaggerated cellulite. Furthermore, there is no way  to predict how these artificially corpulent gluteals will age with further time. Unfortunately in 2017, there is little to be convincingly done to remedy such a situation. Lest this be a caveat for those seeking buttock super-sizing regardless of the method employed. Dr. Haworth 2017

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

Open or Closed? the Pitfalls of a Cookie-Cutter Rhinoplasty.

New techniques always emerge which supplant the old. The same is true with the plastic surgical procedure called rhinoplasty, or in common parlance, nose job. A nose is basically composed of three materials: overlying skin with associated fat, bone and cartilage.


A rhinoplasty involves:

  1. changing the shape and slant of the bones through selective filing and cutting
  2. changing the shape of the cartilages through removal, adding and reshaping with sutures and
  3. in selected cases, “defatting” the skin to allow the shape of the cartilages and bone to “shine through”.  

In order to perform the rhinoplasty, the surgeon must gain access to the underlying bone and cartilage through either through a closed or open technique. The former involves making incisions confined to within the nostrils and performing the surgery through the limited exposure that these incisions thus provide.  The latter, open technique, involves making the same incisions within the nostrils but joining them across the columella (the fleshy partition that separates the left and right nostril at the base of the nose).

I am frankly surprised and amused that in 2017, some plastic surgeons still insist that the closed technique, when “performed properly”,  provides equal or even superior results than those obtained with an open one. These same surgeons cite a few old masters of closed rhinoplasty from  the 1970s and 80s to support their contention that the closed method is superior. However, the best results from these old Masters do not parallel those obtained from top rhinoplasty surgeons today. Whether you like it or not, progress is inevitable and the new masters of today produce better results than the masters of yore.

I recently attended two conferences  hosting some of the top thought leaders in rhinoplasty surgery. As expected, there was not one expert in the room who would consider closed rhinoplasty an option to achieve the delicate and precise results expected by their patients.  Indeed, even in their hands they  felt that a closed rhinoplasty generally leads to a subpar result. Imagine having to work on the engine of your car only through the left and right front wheel wells. Without opening the hood to gain full unimpeded access to the engine, your ability to effectively work is exceedingly hampered.

The results of any plastic surgery should be measured by the end visual result and not by the process to achieve it. 

Those who promote closed rhinoplasty as better invariably cite less swelling and no potentially visible scar as their main selling point,  but this is a fallacious argument. When properly performed, as a top Beverly Hills rhinoplasty expert, Dr Randal Haworth has seen minimal to no difference in postoperative swelling between the open and closed methods and the scars essentially become invisible whether you are a young model or a 70-year-old person. The proponents of closed rhinoplasty  proudly display their early smooth and symmetrical results as being superior. However, in the early postoperative period, it is the very swelling that the closed proponents claim is not there that may be masking inaccurate nasal construction below. This can be seen in the many examples of  famous noses heralded in their early postoperative period but turn out poorly constructed when their swelling dissipated. Generally avoidable deformities such as inverted V deformities, pinched tips and crooked noses become unavoidably visible no matter how much makeup contouring and good lighting is available.

Famous Noses and  Deformities via Closed Techniques:

After closed rhinoplasty with obvious ‘inverted V” deformity, pinched tip and lack of harmony between the upper and lower portion of the nose
Bella Hadid with nasal deformities after closed rhinoplasty
Note the lack of continuity between the upper bony portion of the nose and the lower cartilaginous portion. An obvious “inverted V” deformity and pinched tip do not help the situation.
Ashlee Simpson with nasal deformities after closed rhinoplasty
After a closed rhinoplasty, note crooked appearance, asymmetrical and drooping pinch tip
                         

Examples of Complex Rhinoplasties Performed through the Open Technique:

Open rhinoplasty
Significant congenital asymmetry of the nostrils. After an open rhinoplasty-note significantly improved symmetry with minimal scar that a closed rhinoplasty technique can’t achieve
Unfortunate result from a closed rhinoplasty with “inverted V” deformity and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Unfortunate result from a closed rhinoplasty with “inverted V” deformity, retracted nostrils and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Unfortunate result from a closed rhinoplasty with “inverted V” deformity, retracted nostrils and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Another example of noticeable congenital asymmetry of the nostrils. After an open rhinoplasty-note significantly improved symmetry with minimal scar that a closed rhinoplasty technique can’t achieve

When precise control over the shape and symmetry of the nose is required as well as control over the subtle light reflexes and shadows embodying the beauty of a nose, nothing beats an experienced surgeon with a precise touch, an aesthetic sensibility and an open rhinoplasty technique.

Dr.Randal Haworth

2017

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