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.
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
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
While we in the cosmetic industry are getting better and better at delivering the results that patients expect, I still hold fast that 60 to 70% of modern high-tech materials and devices in plastic surgery over promise and under deliver ! Considering that the future of plastic surgery will be less about actual surgery as more more and more technological advances are made in the lab (think genetic engineering, better fillers, better lasers, etc.), this 60-70% statistic is rather disappointing. What makes this all the more egregious is the fact that doctors are forced to pay an arm and a leg for such underperforming technologies (Ulthera ® Thermage®, etc.). In light of the fact you can get a state-of-the-art Tesla with all the bells and whistles for around $100,000, paying $150,000 or more for a machine that just delivers fuddy-duddy ultrasound technology through a wand to aid in liposuction is frankly outrageous. However, the medical tech companies can’t be solely blamed for this-they are basically governed by the FDA’s policies which, in turn, are a response to precedents extrapolated to an absurd degree by lawyers. Unfortunately, I have seen it all too many times – a new plastic surgery technology coming out amidst a flurry of media only to fade into relatively rapid obscurity. This is similar to a Billboard chart topper only to turn out to be a one-hit wonder! In my opinion the latest overhyped snakeoil is Kybella® from the big pharma conglomerate Allergan®, proud makers of Latisse®, Botox®, Voluma®, Juvéderm®, etc. I was glad to hear from some of my esteemed colleagues at the recent American Society of Plastic Surgery meeting in Los Angeles that their thoughts on Kybella ® echoed mine. Taking into account Kybella’s negative points, which include: 1. relative risk of damaging important facial nerves, 2. cost (though one treatment is less expensive than liposuction, more often than not multiple treatments are necessary and these, of course, add up), 3. associated pain, 4. longer recovery (which, ironically, is worse than surgical liposuction since remarkable swelling can occur after every injection session) and 5. inferior results to those obtained with aesthetically and skillfully performed liposuction …there is little to no advantage in utilizing Kybella® for my patients except perhaps for its superior multi-million dollar marketing campaign! Indeed, micro liposuction can provide unprecedented control in removing fat to treat a double chin while refining the jawline and addressing the jowls as well-all with less downtime and more economically so in the end. Case in point:
By trade-offs, I am not referring to complications or risks.
By trade-offs I am referring to subtle and sometimes significant alterations in your appearance that will be incurred by undergoing a certain plastic surgical procedure. It is the doctor’s responsibility to inform the patient of these trade-offs (including risks of complications) while it is the patient’s responsibility to make an informed decision to proceed if he or she feels that the benefits of the surgery will outweigh the risks and trade-offs.
Examples of such trade-offs are the scars in and around the ear that result from a facelift. Even though they may be near invisible, they are scars nonetheless. The majority of patients feel that benefits of the facelift outweighed any of the associated trade-offs. Similarly, patients who undergo an abdominoplasty (tummy tuck), mastopexy (breast lift) or brachioplasty (arm lift) should be fully aware that they will develop scars from those procedures. Though the majority will heal well with very acceptable scars, most of the time the scars will be visible to some degree.
Patients who undergo a rhinoplasty must understand that their nose will be numb, stiff and hard for up to 3 months or more while swelling can persist for 1 to 2 years. Numbness from a facelift or a browlift can last many months as well. Despite understanding these trade-offs, the vast majority of patients have no problem undergoing these procedures once they have decided to do so.
Over the years, I have found it curious that a small minority of patients undergoing lip reshaping surgery in the form of upper lip lifts and V-Y plasties had unrealistic expectations in terms of their healing and results. They were surprised even angry that they experienced numbness, stiffness and associated scarring. Sometimes a very subtle change in the nostril position occurred after the surgery. These trade-offs may arise even though the result of the upper lip lift is successful from the aesthetic standpoint-in other words, the net benefit in the sensual-youthful-beauty quotient for the face has been increased. However, a few may consider the lip lift a failure if they have experienced even a slight degree in any of these trade-offs.
Though these trade-offs can mostly be successfully reversed, a patient should not elect to undergo such a procedure if he or she will not accept that these can be normal aspects of the procedure. If one thinks about it, an upper lip lift will have its trade-offs in the same way other procedures would have their own yet it perhaps gets more attention than other anatomical features of the face because the lips are expected to not only look beautiful but also function as well.
And function they do, more than any other part of the face. Indeed, lips are used to express, emote, eat, kiss and speak-essentially they move millions of times a day! Because of these strong repetitive muscle forces around the nasal and oral region the plastic surgeon must create a strong upper lip lift that will resist these forces in order to achieve a result that is long-lasting, with minimal scarring and nasal distortion.
In fact, lip shaping procedures are the most challenging of all facial plastic surgeries, even rhinoplasties. Though the success of facelifts are measured in centimeters, brow lifts in increments of 2 to 4 mm and rhinoplasties in millimeters, lip reshaping surgery is measured in quarter-to-an-eighth of a millimeter! With those scales, one can almost consider this close to microsurgery.
In 2014, it would be a miracle to undergo an upper lip lift with an unequivocal guarantee of no scarring, nasal distortion, prolonged minor sensory changes and stiffness. If you are contemplating undergoing an upper lip lift but will not tolerate any of these tradeoffs, I suggest you avoid the procedure altogether and wait for that miracle to happen.
Lip lifts for 2014
Patients often asked me what are the differences between a skin-only lip lift and my muscle hemming technique. To put it simply, longevity, scarring and nasal distortion.
Skin Only Lip Lift
Until the late 90’s, the only lip lift I knew how to do was the skin only type. I would perform this by excising a certain amount of skin below the nasal base and sewing the lower edge of the excision to the upper edge which happens to be the skin of the nose. The only thing now supporting this entire weight of the upper lip (which happens to move millions of times a day, eating, kissing, expressing and speaking) is the freshly closed incision at the skin level. One can imagine that this provides little support for all the action occurring around the upper mouth area. Consequently, the longevity of the lip lift itself is lessened, the nostrils are more likely to be pulled downwards while the resulting scar is more likely to stretch and thicken.
Muscle Hemming Lip Lift
After many years of observing the long-term results of skin-only lip lifts, I developed the muscle hemming technique. By employing moderate principles of plastic surgery in which nip and tucks (such as a facelift) are improved by lifting and tightening the layers below the skin including muscle I have noted a significant benefit to my lip lifts in terms of scarring, longevity and less nasal distortion. However, the recovery period was notably increased. The muscle hemming technique involves placing slowly dissolvable sutures into the muscle layer below the skin and intern suturing that to the periosteum (lining) of the bone deep to the nose itself. The lip lift is thus a solid one without relying on skin closure to achieve its superior long-term results while lessening the chance of undesirable scarring and pulling around the nostrils.
Skin Flap Lip Lift
Which brings me to today. For the last 3 years I have been employing a skin-flap technique which provides all the benefits of the muscle hemming technique but with half the recovery. Suturing of the muscle is minimized in this technique but none of the longevity and superior scarring is sacrificed. The period of significant distortion and swelling has been halved from 2 weeks to less than 1. Additionally, the results are “softer” in appearance with minimal to no distortion of the nostril area.
Performing the modern lip lift with minimal-to-no-scarring and achieving a permanent beautiful result is challenging . It requires attention to minute detail and appreciation of how the oral region plays a central role in facial harmony. The vast majority of patients are thrilled with the subtle yet powerful results of this operation, but it has taken over 2 decades of unwavering dedication and imagination to get this far.
To view more upper lift results go to:http://www.drhaworth.com/procedures/upper-lower-lip-lifts/