The pinched nose; the rhinoplasty gone “wrong”

Posted on by omnispear
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 www.drhaworth.com or call his office in Beverly Hills to schedule a consultation.

ZenTox™East meets West cosmetic treatment

Posted on by omnispear
For the last three years, I have been  grafting certain concepts of Oriental philosophy and medicine onto my Occidental plastic surgical practice. Some  of these  chimeric treatments have really resonated with my patients, one especially in particular. This involves the simultaneous application of hot and cold jade stones during my administration of Botox ™(botulinum toxin type A.). Alternatively, this concept could also be used for  injections of Dysport™ and Xeomen™,  both new FDA approved paralytic substances for cosmetic use. I have coined  Zen-Tox as a readily identifiable term describing  the novel use of distraction from pain via temperature.

To read more about this unique procedure which actively decreases the discomfort experienced during facial injections, refer to  Dr. Randal Haworth’s recent interview in Ocean magazine by clicking the following link.

Zentox

The Tricky Rhinoplasty and Upper Lip Lift Combination Surgery

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

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



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

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

Patient 1.Preop: 52 year old female



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

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



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

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

Rhinoplasty Philosophy – Dr. Randal Haworth

Posted on by omnispear
Rhinoplasty, or what people refer to in colloquial parlance as “nose job” surgery, is one of my favorite specialities. I have performed literally thousands of these challenging procedures as far afield as the Middle East, Europe and South East Asia. What I find so fascinating about rhinoplasty is how it can impart such dramatically positive change to the face as a whole – a classic case of the final result being greater than the sum of it’s parts.

Not only do I find it immensely gratifying to invent new solutions to challenging problems, I actually like the ” feel” of the surgery- the intricate interplay between skin, cartilage and bone. Even after 16 years of private practice, I discover new, exciting nuances in techniques that the average surgeon performs without feeling. Though I considered myself “top of my game” at the time I was doing plastic surgery on ” The Swan” in 2004, I look back upon those patients today and realize I could do better on a third of those rhinoplasties I performed! Like an artist, I always aim to do better and realize that my work today is better than it was in 2004 and will be better still 5 years from now, barring some personal tragedy.

The first era for me in rhinoplasty surgery was about creating beauty and my second era is about controlling beauty- imbuing a subtle softness into the result, and erasing all signs that humans hands had anything to do with the patient”s nose. A good pianists doesn’t just play the notes and chords accurately but also with crescendo and pianissimo- with feeling. My next series of blog posts will revolve around the subject of nasal surgery and aim to share with you certain concepts, both basic and advanced, that are important to both the lay person and surgeon alike.

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

Bristol Palin’s new look

Posted on by omnispear
Bristol Palin sports a startling new look, especially around her jawline. BP after surgery

Bristol Palin looking as if she had too much vertical chin elongation from a sliding genioplasty or a misplaced chin implant

She attributed her change to necessary  “corrective jaw surgery” and not plastic surgery. Firstly, that is hogwash since corrective jaw surgery is a form of orthognathic surgery which lies in the realm of plastic surgery. It was obviously performed partially to change her appearance, most probably via a “sliding genioplasty”. A sliding genioplasty involves sawing the lower aspect of the chin bone away from the actual lower jaw bone and either moving it forward, downward or both at which point it is then stabilized with a screw. It  seems that Bristol had her chin moved both forward and downward to correct skin redundancy around her chin area. I frankly am not enamored with the look since it makes her chin too pointy and distorts her original facial harmony. However, this pointy look is lessened if she looks upwards towards the camera thereby moving the offending outgrowth further away from the lens.

Her pointy look is lessened if she looks upwards towards the camera as demonstrated in this photo

Bristol was actually prettier before the procedure (especially before her weight gain)  and it seemed all she needed was some weight loss, strategic liposuction of her jawline and neck and perhaps a  chin augmentation  with a small implant, positioned in such a way as to not elongate her chin.
Bristol Palin pre-plastic surgery
As Mark Twain wrote: ” To not read the newspaper is to be uninformed, but to read the newspaper is to be misinformed”. All blog posts on this website are meant for public educational purposes only.

The Best American Board of Plastic Surgery Test Result

Posted on by omnispear
In order to maintain the highly esteemed status of being “Board Certified” by the American Board of Plastic Surgery, Inc. a plastic surgeon must maintain his or her credentials throughout their career. Not only does the plastic surgeon need to continuously attend courses while embracing the highest ethical standards, he or she must also pass a rigorous board recertification exam every ten years. Dr Haworth scored 100%, the best score  a plastic surgeon can obtain in the United States. Dr Haworth is proud to be a board certified plastic surgeon.

Dedication to Excellence

When do breast implants need to be changed?

Posted on by omnispear
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.

Virtual Consultations

Posted on by omnispear
Up to 45% of my patients come from out of town, out of state and abroad. Obviously, a number of challenges are posed when initially consulting such patients due to geographical restrictions. Fortunately, due to the technological advances of today’s Internet, such as VOIP with videoconferencing and e-mail, both the patients and the doctors can get a sense of each other before they actually meet in person. Even though such a “virtual consultation” cannot substitute for a detailed face-to-face physical exam and interview, it does provide an initial backdrop for the surgeon to assess what the patient’s goals are, whether they have realistic expectations and lay down a framework for a particular surgical plan of action. In turn, the patient can assess their individual comfort level with the doctor, whether that doctor can potentially fill their goals and at what approximate price. One must realize that these “virtual consultations” cannot substitute for an in-person consultation nor can they be construed as offering definitive medical advice to a patient. They only serve as tools to facilitate a potential doctor-patient relationship, saving time and the expense of traveling to the doctor for a consultation if it is already obvious that it would be fruitless.

If you are choosing to communicate with Dr. Haworth via e-mail, etc., it is necessary that you send him properly taken photographs of the area or areas of your face and body that are bothering you. As a guideline facial photographs should be taken from four angles.

AP View   Oblique View
The first one is an AP (anterior-posterior) view   The second one is an oblique view (note how the tip of the nose touches the far cheek edge)
 
Profile View   Worm's eye View
The third is a pure profile view (with the eyes looking straight ahead)   The fourth view is called the worm’s eye view (this is only needed in rhinoplasty surgery).

 

For the body, these same rules of thumb apply. Simply send well-framed photographs of your troublesome area (whether it be your hips, abdomen or breasts) in an AP, oblique and lateral view. Make sure that the photographs are taken at the appropriate distance-it is important that Dr. Haworth can get a sense of how your breasts, for example, relate to the width of your hips and waist. If the photographs are taken too close, anatomic proportion may be very difficult to assess.

 

Stem Cell Facelifts

Posted on by omnispear
There was an interesting article today in the LA Times. It was focusing about a new trend to offer so-called stem-cell enriched facial rejuvenation procedures. While there is an obvious knee-jerk, almost giddy appeal to such a sexy newsworthy procedure, there is also a more scientific and sober take on the subject.

Before I begin, one must first understand that these stem-cell facelifts are basically high-priced fat transfers that are supposedly enriched with stem cells. They are branded under many different names such as Stem Cell Facelift®, FAMI, Naturalfill® , Celution, etc. Experienced fat grafting surgeons have long known that successful fat grafting is highly dependent on the techniques used for extracting, processing, and reinjecting the fat cells. Surgeons are beginning to understand that fat processing techniques which result in high concentrations of adult stem cells produce not only long lasting results, but also have therapeutic results in injured tissues. However, it is already well accepted that properly performed fat transfers already come replete with stem cells.

I have been performing fat transfers for over 15 years and know that the results are often spectacular and permanent, recreating youth not only in terms of facial contour but also in terms of skin quality. I realize that stem cells are a normal component of the fat-mix that I or any other experienced plastic surgeon transfers and success basically relies upon the surgeon’s technique and artistry. Those that claim they have the magic-mix or snake elixir because they utilize stem cells in their fat transfer are essentially taking credit for the sky being blue. Their claims of superior results are currently unsupported and amount to nothing more that marketing- a way to get more patients in the door and charge higher prices. It is also important to know what these practitioners are comparing their so-called superior results to- facelifts, fat transfer, Restylane or a healthy diet?

My concern with the “stem cell facelift” is not that it’s a bad procedure, but rather that this is not the most accurate description. Some doctors even feel that calling fat grafting a “stem cell facelift” is misleading. When seeking treatment, make sure that your surgeon relies on science, experience, and skill rather than catchy marketing phrases.

For more information, go to the source, read this article and decide for yourself: Stem Cell LA Times Story

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