Recently, the Health & Wellness section of the Los Angeles Times had two excellent articles that dealt with the problem of sleep apnea and snoring

According to the Los Angeles Times, “2% of women, or at least 4% of men, suffer from obstructive sleep apnea.”  If you are not familiar with sleep apnea, it is a condition “in which the airway collapses and blocks breathing for 30 seconds, or even up to a minute or two.  The brain senses that it isn’t receiving enough oxygen and sends a signal to the patient to wake.”

People with sleep apnea (apnea is translated as “without breath”), find themselves in an unsatisfactory and untenable situation because their sleep quality is poor.  Poor sleep quality can generate  a myriad of problems including sleepiness at work and leisure, and even possible elevations of blood pressure, and other imperfections in your normal bodily function.

Maybe there is a connection between the rise in obesity in the United States and sleep apnea.  The paper says, “the incident rises with age: experts estimate that it affects about 40% of people age 65 and older.”  What we are seeing in the United States is that older people tend to be heavier.  That is not good news on many fronts. 

The articles also points out that it’s not just about age.  The overweight issue is very significant.  Overweight patients have double the risk of sleep apnea according to Dr. Lawrence Epstein, of a sleep center chain in Massachusetts.  Incidentally, if you have ever seen kids with large tonsils and adenoids struggling to get breath when they are sleeping at night, which is not that uncommon, you have a clue as to what sleep apnea is like. 

The article pointed out that there are mechanical remedies available including the infamous CPAP (“Continuous Positive Airway Pressure”) device, which is a spaceman-like mask which affixes tightly and to the face, akin to a scuba mask.  An external electrical power source drives the air into the lungs under pressure at night.  It is not too pretty; but, it does provide relief for people. 

Other technical aids are dental mouth pieces, and even some of these external nasal breathing strips. 

I was a bit disappointed that the article did not discuss management of one of the key causes of sleep apnea – that is a blocked nose. Nasal obstruction.

More on that to follow because there is a huge pool of patients in the United States, and worldwide, whose problems can be helped with a veteran, venerable, and reliable one-hour surgical procedure – nasal septoplasty and turbinate resection, with or without rhinoplasty. 

~Robert Kotler, MD, FACS

Several months ago, the United States Food and Drug administration gave approval to sell Allegra, an anti-allergy pill, without a prescription.  The entire Allegra family of products will be available on drug store shelves.

The product has been on the market for quite a few years and there are other products that purport to provide the same benefit.  The rationale for taking these medications is that through certain biological pathways, the medication will blunt the effect of those substances to which the body is allergic.  It is the allergic reaction which causes the symptoms of blocked breathing, runny nose, itching, sneezing, watery eyes, etc.  It’s no fun.  I can tell you from my own experience that as a child and adolescent, I had quite bad allergies particularly to ragweed which is endemic during the late summer in the upper midwest. 

According to the Asthma and Allergy Foundation of America, there are approximately 40 million Americans who have both indoor and outdoor allergies.  According to the article, the most common triggers are tree, grass and weed pollen; mold spores; dust mite and cockroach allergen and cat, dog and rodent dander. 

One issue that always comes up is how effective are these medications in terms of relieving the blocked breathing.  It has been my observation while they can be helpful when alleviating the other symptoms which besides those mentioned above can include even a scratchy throat and a red and unique sensation of itchiness in the throat.   But, I find such pills, tablets, syrups or whatever woefully inadequate in providing a normal airway for patients.

I realize I’m taking issue with a huge economic force, a large commercial market selling billions of dollars worth of medications – prescription and nonprescription  – to the public with the promise of helping breathing.   In my opinion, there is no substitute for the one-time, one-hour surgical procedure that for nearly every patient will bring lifetime relief.  The classic and typical procedure is correction of a deviated septum, if that is a factor and it often is, and thereby restricting the airflow regardless of the status of the lining of the nose which is the target for the allergic reaction, and most importantly, trimming by various means including surgical excision, laser, and other technologies, enlarged turbinates.  The most commonly enlarged turbinates are the right and left inferior turbinates.  While there are a total of six, three on each side (upper, middle and lower turbinates), it is the lowers that have the greatest potential for severe swelling as the lining is attacked by the allergen.  Incidentally, the same process takes place when you get a cold.  In that case, the virus invades the tissue inciting a reaction by the body causing the lining to swell.  When the lining swells, the diameter of the air passage in the nose diminishes.

I am an advocate of the surgery because patients appreciate that it is a one-time cure.  As one doctor-patient unfairly credited me with a big victory:  “Dr. Kotler, you cured my allergies.”  I really didn’t cure the allergies.  But what my surgery did was create such a large internal nasal airway that even when he had an allergic attack, and the lining swelled and thus diminish the airflow, there was so much extra room that he could still have satisfactory breathing. 

I liken it to converting a two-lane highway to a four-lane highway.   Even if there is a minor accident – the analogy here is that the accident is either an allergy attack or cold – there is still room for the airflow or traffic to pass.

Recently, I made my contribution to improving that operation by developing what is now known as the Kotler Nasal Airway.  This is a right and left medical grade silicone soft tube that the surgeon seats on the floor of the nose after the corrective nasal surgery that allows the patient to breathe despite the rest of the nose being swollen and/or being packed with various cotton-like substances that surgeons use to help keep the tissues in proper position and reduce bleeding. 

The patient satisfaction rate for the operation itself has been high but the postoperative period, heretofore, before use of the Kotler Nasal Airway, has been less than popular because of the misery of what one patient described as “feeling like I had a clothespin on the tip of my nose for five days.”

Science never sleeps.  We move forward and any contribution that makes an operation more palatable, comfortable and successful is always welcomed.

~ Robert Kotler, MD, FACS

 Recently, a press release from one of the plastic surgery trade organizations reported that there was an increase in activity in the plastic surgery community.  That was said to be harbinger of better economic times to come. 

Frankly, I am not so sure of that.  The growth in cosmetic procedures is not in the surgical arena.  It is in the non-surgical office treatment arena.  So, as I see it, the increase in the “ plastic surgery business” is not in the plastic surgery but in the syringe and needle department.

Botox Cosmetic, Dysport, Restylane, Juvederm, Sculptra, and Radiesse, Artifill and medical-grade liquid silicone are all good and valuable treatments that patients are flocking to. 

We cosmetic surgeons are glad to have these excellent products available to us, but the reality is, alone, they cannot do the job.

Today’s patients, watching their budgets, are apt to opt for the non-surgical treatments before the more major treatments, such as face and neck lift, neck sculpture, upper and lower eyelid surgery, brow lift, chemical skin peel, or laser skin treatments.  It is understandable. Office treatments require no time off, are virtually painless, and are far less expensive. 

It may be that we never reach the numbers of surgical procedures that were done before the current Great Recession.  While the cutting and sewing procedures are available for patients, the utilization may be less because of economics, primarily.  Understanding that, many practices are offering reasonable discounts to aid people who might otherwise not be able to afford the procedures.

When consulting with doctors, be sure to ask about all treatments available, both surgical and non-surgical. And, ask how you can shave some dollars from the cost without sacrificing quality.

I have some hints on that for you on a future blog post.

Recently, one of our patients, a registered nurse having a face and neck lift, commented that the anesthesia experience was “So terrific.  I found it astonishing.”  This veteran nurse practiced in a previous era where, frankly, the practice of anesthesia did not deliver the same level of patient comfort and safety.  All this has to do, really, with the drugs that are available, but most importantly, the technique and bedside manner of the anesthesiologist.

The anesthesiologist for this procedure was Barry Friedberg, MD, faculty member at UC-Irvine, and author of  Getting Over Going Under.  Dr. Friedberg is the world’s leading authority on a particular anesthesia technique which is extremely appropriate for face and neck lifting.  It is known as “PK Anesthesia” – “P” for propofol and “K” for ketamine.  This is essentially a very sophisticated sedation formulation accompanied by brainwave monitoring by the anesthesiologist.  Brainwave monitoring is the key to the proper level of medications being given to the patient. Not too much and not too little is the key.

One of the great virtues of this technique is that there is no tube placed into the windpipe; therefore, there is no throat irritation.  There is almost no chance of postoperative nausea and vomiting.  The patient wakes up quickly and comfortably without any bizarre dreams.  There is no evidence that this technique leads to any brain cell damage, which other techniques are now being linked to.  So, there should not be either  loss of memory nor any other intellectual faculties. 

What I like about the procedure is that it is simple, predictable, and with only two drugs being used, not much can go wrong.  Knowing that Dr. Friedberg is reading the brainwave monitor is as comforting to me as knowing that a cardiologist is reading my patient’s EKG. 

Anesthesiologists are “the second doctor in the operating room.”  While patients rarely develop as deep and long a relationship with them as they do with their surgeon, thoughtful surgeons recognize that the experience the surgeon brings to the patient, in terms of comfort and safety, is dependent upon the anesthesiologist. Great value there.

Today, anesthesia is safer than ever.  The reason is giant strides towards patient safety and comfort achieved by the specialty of anesthesiology. 

Several patients have asked me whether it is necessary to have an anesthesia specialist.  They ask, “Is it not possible to do the procedure under local anesthesia, without an anesthesiologist?”  I think this question is being posed because there are some marketing companies that promote “lunchtime” or “one-hour” or “quick” facelifts, whose patients do not have the benefit of an anesthesiologist. 

Not having that “second doctor” in the operating room is one of the most foolish decisions a patient can  make. For cosmetic surgery–or any surgery.  Why wouldn’t you have a specialist whose entire work is devoted to patient comfort and safety?  Is anything more important than either for you?  Today’s anesthesia is so safe that, in fact, you’re safer in a certified outpatient surgery center or hospital, with a doctor anesthesiologist at your side, than you are on the freeway or road you took to get to the surgery center! 

Finally, if people are attracted to a program that does not include an anesthesiologist within the package of services, consider that the anesthesiologist’s fee typically is no more than 10% of the total outlay for all services, including the surgeon’s fee, outpatient surgery center or hospital, postoperative medications, and postoperative recovery facility. 

It’s a false bargain to try to save money when your very life is on the line. 

CONSIDERING RHINOPLASTY?  BE SURE TO CHECK OUT YOUR CHIN ALSO.

Many people have rhinoplasty because they are not satisfied with their profile.  There might be a hump or the nose may project too far from the face.  The nose may be too long ; even  “so long” that it nearly touches your lip when you smile.  Most people do not see their profile and, rarely, can make the same objective judgment about their nose that they can about the width, which is visible from the front.  Often, photographs are what drive people to see us for consultation concerning their nose because, “Whoa, I saw what I look like from a side view, and I sure don’t like what I see.”

A complete consultation will include evaluation of the appearance of your nose in all views.  The wise cosmetic surgeon, or plastic surgeon, or facial plastic surgeon will also take into account the dimensions and position of the chin.  It is very important because often the nose appears unduly large because the rest of the face is not large enough.  In other words, there is a disproportion between the nose and the face based on how the other facial structures are formed and what their dimensions are.

The chin often needs to be augmented.  In other words, the profile is improved if the nose is made smaller, and the chin is made larger on the profile.  I am not talking about looking like Jay Leno.   But, I am suggesting, and in some people, just a very small increase in the forward projection of their chin will compliment the improvement in the nose and make the profile as good as possible.  At consultation, it is very important that all aspects of your appearance be considered.  Do not go in with a narrow-minded view of “I need a rhinoplasty.”  The point of consultation is for you to learn and understand what the anatomic issues are.  If the surgeon suggests that you consider a chin implant, do not take it as an insult, but, rather, that the surgeon is thinking about your entire face, and that is exactly what his mission should be.

After nasal surgery, cosmetic or reconstructive to improve nasal breathing, there is generally some sort of “packing” placed inside the nose.  The same process for people having a nasal and sinus surgery.  Whether it be a cotton pad or Telfa, or cloth-like material, the purpose is to maintain the reconstructed parts in the proper anatomic position, reduce the chance of bleeding, and to deliver important medications into the tissues, such as antibiotics and even medications to speed healing.  So, packing has always been a traditional part of rhinoplasty, nasal septoplasty, and turbinate resection, but not necessarily welcomed by patients. 

Patients, understandably, dislike the complete blockage, the feeling as though “there is a clothes pin put on my nose.”  They do not like it because it produces a dry mouth and, worse, a sense of anxiety that they cannot catch their breath.  One patient likened his experience to being “waterboarded.”  Another said it was one of the worst experiences of his life because he was very anxious, he could not sleep, and was “generally miserable.”

Interestingly, the specialties of facial plastic surgery, head and neck surgery, ear, nose and throat and general plastic surgery have not paid enough attention to  patient satisfaction with the post-operative experience. While the results of the rhinoplasty and other procedures generally been good, patients rarely give high grades to the experience.

With that in mind, recently, I have developed a new medical device that allows patients to breathe completely freely and normally during the entire postoperative period, including right after surgery.  This Kotler Nasal Airway is placed by the surgeon at the operation, and then the packing is placed.  So, the airway is guaranteed, and the comfort and security of being able to breathe is assured. 

More to follow on this later.

Beverly Hills Rhinoplasty Cost

Patients always wonder whether or not there is a “excise tax” placed upon surgical fees in Beverly Hills.  In other words, are people paying for the location, perhaps, without any correlation with quality.

The hard economic reality is that the costs of doing business are higher in Beverly Hills.  Particularly, the so-called “Golden Triangle,” where there is an extremely high concentration of some of the most sophisticated specialists – in all areas of Medicine – residing.  It is a medical campus without a hospital.  But, there are many outpatient surgery centers for the types of elective surgery that we perform, for example.  So, yes, the cost of doing business is higher in Beverly Hills, and, therefore, the surgeon’s fees may be a bit higher.  But, they are not double or triple what they are elsewhere. 

There are advantages to seeing doctors who are at the top of the list of super specialists because they tend to be the most proficient in the procedures they perform, and they tend to congregate together.  The reasons why the highest quality physicians and cosmetic plastic surgeons tend to congregate is that there is ease of consultation and referral.  These translate into significant benefits for patients.  Some of our patients come from out of town and appreciate the fact that we can make arrangements with the other specialists whom they may want to see for other services.  For example, patients often come to see us to have rhinoplasty, cosmetic nasal surgery, and also septoplasty and turbinate resection for breathing.  They may also want to have breast augmentation.  We have a very close working relationship with some of our plastic surgery colleagues who specialize in body plastic surgery, and; therefore, are super specialists “below the neck,” as we are super specialists “above the neck.” 

Typically, fees for cosmetic procedures do not have that wide a variation.  Therefore, while it may cost perhaps 10% or 20% more to have the procedure done in Beverly Hills, most patients feel that, indeed, “you get what you pay for,” and if the most highly skilled, most super specialized doctors are in Beverly Hills, because they are there in a central location surrounded by other top specialists then, it is not unreasonable to pay a bit more. 

Now, Heidi Montag is complaining that she had too much cosmetic surgery.  This lady really knows how to work the media and get some press. 

Apparently, Heidi made the comment that of all the ten procedures she had on that one marathon day, the ear surgery, known as otoplasty, was the most painful.  I guess she has to say something to fill the pages of the newspapers.

I don’t know why she found the ear surgery so uncomfortable.  Our experience has been that it is not painful unless there is a complication whereby blood leaks under the skin, is trapped, the skin expands and causes pain.

We take every precaution to prevent that, of course, with very meticulous sealing of blood vessels and placing what is known as a “drain” which is a rubber band-like strip of fabric or rubber to encourage migration from inside to outside of any fluid that accumulates underneath the skin.

Know that the incisions are hidden behind the ear and are typically closed with absorbable stitches. 

No patient should ever suffer from pain.    With the large variety of pain medicines, why should anybody be plagued with pain?  If one does not work, we merely prescribed another.  We go up the line until pain relief is achieved.  Sometimes we have to use very strong pain medications like Percocet or morphine or Demerol but that is rare.  Most patients having routine cosmetic facial and body surgery get along very well with mid-strength Tylenol with codeine or Vicodin. 

As a matter of fact, excess pain is a warning sign, as I mentioned above, possibly heralding bleeding or fluid collection underneath the skin.   So when we hear that the patient is having pain, particularly if their pain medication requirement is going up, we need to see them and make sure that nothing bad is happening.

As in all areas of surgery and medical practice, early recognition of complications and problems is essential.

 “Why Did I Wait So Long?”

We always hear that from patients who delayed having surgery to improve their breathing.

Those patients with blocked noses or a nose that is not attractive typically started out early in life with that problem.  It is not a matter of aging.

Patients with deviated septums, uncorrected nasal fractures and enlarged turbinates due to allergies, typically are plagued with these conditions for many, many years before they start to do something. For some, the nasal blockage pre-disposes them to sinus infections.

Frankly, some of our brethren in other medical specialties do not recognize the architectural problem soon enough.  A good family practitioner or internist should be able to evaluate the inside of the nose to see if, in fact, there is a deviated septum and/or enlarged turbinates or crookedness of the entire nose which could be contributing to the blockage causing the misery that follows a cold or allergy attack.

It is not normal to not be able to breathe. Period.

Our happiest patients are patients where we correct the deviated septum, trim the turbinates and also do rhinoplasty to improve their appearance because in one two-hour session, they have not bettered their quality of life for the rest of their life.  It is so great to do teenagers with these problems because they will not be plagued being self-conscious about their appearance or suffer from blocked noses for another 60, 70 or 80 years. 

Recently one of our patients came and uttered that often-heard remark, “Why did I wait so long?”   Well one reason was he really was afraid to have it done because he was concerned about what he heard from other people who have had the operation.  There is a little bit of “bad press” going on out there, not because of the operation itself nor the results.  It is because the pos-toperative period has been uniformly unpopular since the surgeons have had to put packing of some form inside the nose.  Unless some provision is made for providing an airway through the nose, packing equals total nasal blockage. Not fun for the patient.

Packing is placed by surgeons performing rhinoplasty, correction of deviated septum, turbinate surgery and sinus surgery because it is important to help control bleeding following the operation.  Also, today’s packings which may be cotton-like, gauze-like or even a thick liquid gel, have antibiotics and even other ingredients such as bioengineered healing factors which hasten the healing and reduce the chance of infection.

So the packing, of whatever substance or material, is important.  But the patient’s misery of having a blocked nose for up to five days has long been underestimated by head and neck surgeons, ear, nose and throat surgeons, facial plastic surgeons and plastic surgeons.

One patient likened it to having “to walk around with a clothespin on my nose for five days.”  Another claimed, “I felt I was drowning.”  Patients get anxious, somewhat depressed and complain about the dry mouth and soreness of the throat. 

I have been involved personally in trying to better that situation for over three years.  Working at my “work bench,” I developed a soft plastic airway tube that the surgeon seats onto the floor of the nose and allows the patient to breathe very well after surgery despite the remaining nasal cavity being packed with the usual packing devices or materials.

We have had over 93 patients in our clinical research study undergo the routine surgeries and yet have the benefit of the nasal airway in place.  It wins high grades with 95% of the patients endorsing it.

We always try to do better.  Science never sleeps.  Progress goes on and our aim is to have patients more satisfied, more comfortable under the safest of surgical circumstances.