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Sinus Infections and Septoplasty

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Sinus Infections And Septoplasty

Unfortunately, the sinuses are the much maligned and much blamed subjects of advertisements for decongestant and allergic nose sprays, pills and an assortment of over-the-counter medications.  The reality is that the sinuses are dependent on the nose function. They need to be filled with air that flows into them from the nose. So it is the nose that really deserves our attention.  Consider the sinuses as anterooms that sit astride the nasal passage as a hallway.  You cannot get into your room if the hallway is blocked.   So if the nasal passages are blocked, you cannot expect the sinuses to function normally.

What happens in the case of abnormal nasal architecture such as the presence of a deviated septum (the vertical partition that separates the right and left nasal passage) is that the airflow is inadequate.  When the airflow is inadequate, then the sinuses do not aerate properly.  They may begin to fill with fluid and ultimately cause symptoms.  The symptoms of true sinus infections are hard to ignore:  headache or facial and tooth pain.  The signs are thick and often pus-like drainage from the nose into the throat. Sometimes bleeding.  Patients have a temperature and even nausea and vomiting. A sickness far worse than a “head cold”.

The best way to keep the sinuses healthy and out of trouble is to not smoke and make sure that your air passages are functioning well.  This calls for an examination by a specialist.  It may be that only allergies need treatment with a prescription steroid or cortisone nasal spray.  But for some patients, surgery is necessary.  The surgery takes less than an hour, has been done for over 100 years and is very well established.  The definitive operation is nasal septoplasty to correct the deviated, crooked or broken nasal septum as well as trimming of the inferior turbinates which are normal outpouchings inside the nasal cavity subject to enlargement either from allergy or other stimulations.

Finally, when patients tell me that they have “three to four sinus infections every year” I know they need help. That is not a normal condition.  True sinus infections should be very rare.

Beverly Hills Cosmetic Surgery Fees

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Three Wise and Practical Reasons For Cosmetic Surgeons
To Reduce Fees in a Tough Economy

A very savvy business friend of mine said to me several months ago: “I don’t know of anybody who has not been adversely affected by the very difficult economic times now facing the United States.”

Certainly, when the economy is tight, people have less money available for nonessential services such as cosmetic surgery.  Therefore, plastic surgery practices will see decreasing patronage.  For that reason, practices have to be realistic and ask themselves if there is not a way that they can contribute to helping ease the discomfort of a slow economy and at the same time benefit their practice.

I hereby submit that there are three good reasons why a cosmetic plastic surgery practice is wise to lower its fees: 

1. Physicians have a responsibility to help patients.  If economic difficulties present themselves, there is no reason why we cannot soften the blow by reducing our fees.   After all, physicians who treat illness such as internists, pediatricians, surgeons have treated the needy in exchange for diminished fees.  It is a tradition in medical practice that all be served.  Even though our work is not medically necessary, it is still a valuable and important service to patients.  Therefore, it is perfectly consistent with medical ethics that we lower the economic barrier for the sake of our patients.

2. To be most proficient, surgeons need to be busy.  “Beware of the surgeon who operates infrequently” is an ancient and well-respected axiom in the world of surgery.   My experience and that of other superspecialist surgeons is that in fact, the most gifted and proficient surgeons are busy.  They are busy because they attract patients through their talents.  They are also busy because they will accommodate themselves to the needs of the patients including the economic realities.

3. From a purely business standpoint, it is still better for the practice to do a case at a significant courtesy discount than not to do the case at all.  Medical practices have large fixed expenses including rent and staff salaries.  Accountants have long held that for elective surgery, a practice would be foolish not to discount its fees and continue to keep the operating schedule busy rather than take an aloof and distant stance and pass on surgical cases that would otherwise help the practice and the business’s bottom line.

Beverly Hills Nose Job Problems

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 “My Friends All Have Trouble Breathing After Their Nose Jobs”

                     – patient consulting for nasal cosmetic plastic surgery

This is a very important statement. If a prospective patient believes that the majority of patients who have cosmetic nasal surgery are likely to wind up with breathing problems, then our specialty has a problem.

 

 

 

 

 

 

 

 

 

 

Difficulty breathing after rhinoplasty should not necessarily occur. The competent cosmetic plastic nasal surgeons are trained in the evaluation of the internal nasal structure and the correction thereof.  They need to know if there is a breathing problem before any surgery.  Often, patients are not even aware they have a breathing problem.  It is very easy to check because you ask the patient to close one nostril and with lips closed breathe through their right nostril and then shift the focus to the left nostril as the right nostril is closed.  Very quickly, one gets the airflow picture.

Once the diagnosis of airway obstruction is established, it is incumbent upon the operating surgeon to figure out why.   The most common reasons are that there is a deviated septum which is a crookedness of the internal vertical partition that separates the two nasal passages.  For many patients, particularly those with allergies, there is also the issue of enlarged turbinates, particularly the inferior turbinate.  Turbinates are the three shelf-like extensions that fill a portion of the nasal passages, on each side, to increase the surface area so there is further warmth, humidification and filtering of the incoming air in preparation for inhalation into the lungs. 

If the surgeon diagnoses a breathing problem or such borderline breathing that it is possible that narrowing of the nose as a result of the cosmetic nasal plastic surgery, or rhinoplasty, might throw the patient’s breathing over the edge, it is incumbent upon that surgeon to plan to deal with the blockage and correct it.

My sense is that perhaps a fair number of surgeons who are willing to take on rhinoplasty cases may not be trained in the functional and reconstructive surgery. 

If the doctor’s ego will allow it, when facing an airway problem that he feels he cannot address, the doctor can always call in a consulting surgeon with the “inside” skills to perform that portion of the operation.  After all, it is not unique to cosmetic and reconstructive nasal plastic surgery to have a team instead of a solo surgeon.  It certainly occurs in heart surgery and liver and kidney transplants, etc. It is all for the patient’s benefit.

The recent edition of The New York Times happened to address that very issue whereby some surgeons conceded that it is “normal” to have a breathing problem after some cosmetic nasal surgeries.  I think that is a very damning comment and represents a lack of concern for the patient’s interest.  Steps must be taken to correct the breathing problem at the same time as the cosmetic plastic nasal surgery.

Beverly Hills Cosmetic Surgery, Not Like Dropping-In For a Haircut

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Having Cosmetic Surgery is Not Like Dropping-In For a Haircut

Today our patient correspondent and consultant, mentioned a conversation with a patient from Europe. The patient was coming to us to have nose surgery done and seemed a bit put off when told that it was necessary to make all the arrangements ahead of time.  Ideally, the arrangements would include having a Skype consultation with Dr. Kotler so any questions or issues that the patient wanted to present to him could be done before the patient gets on an airplane and travels thousands of miles to come here.  Secondly, after the Skype session, if the decision has been made to have the surgery, it is very important that the patient have a physical exam and the appropriate laboratory and x-ray work done well before surgery.  After all, if there is a medical problem, surgery cannot be performed.  Cosmetic plastic surgery is only done when the patient’s general health condition is excellent.  There can be no compromises.  So if there is a problem, you surely want to know well ahead of time so that schedules can be amended and most importantly the medical problem could be attended to before flying across the pond.

It seemed that the patient thought he could come in on a Monday, have a consultation and go to the operating room on Tuesday.  And maybe that is because he, as others, tend to minimize the importance of a proper pre-operative evaluation and workup and that everything be put in proper order.

There are logistical issues that have to be considered.  We have to reserve the operating room.  We also have to reserve the doctor-anesthesiologist so that everything is properly anticipated and done properly.  Depending on the procedure, necessary supplies and equipment have to be available and that cannot always be done on a one-day’s notice.

Most importantly, Dr. Kotler and the patient must have time together to discuss the patient’s desires either via Skype or, of course, person-to-person when the patient is here.  Our preference, for patient safety and comfort, is that all possible communications and arrangements be made well ahead of time.   And the patient just doesn’t get off the plane and go to the operating room.  There is always a visit with me in the office one or two days before the procedure.  It is important for me to do a complete examination and determine those things that are not possible to determine via Skype and computer imaging, of course.  I want to explain in detail, face to face, how the procedure will be conducted.  I explain to the patient that the anesthesiologist will call the night before, that the patient will see me in the morning, that the patient will have my home phone and cell phone number so that he knows we are ready and prepared to give the patient the care that he or she deserves.

It may be a tribute to cosmetic surgery that people feel that it is a “minor undertaking.”  If it is a tribute, it is because we have been able to handle all the issues such as discomfort and provide for rapid recovery.  But the truth is, we do not treat it with any less importance than a neurosurgeon treats a patient upon whom he will be doing brain surgery.  After all, we trained as long to do our work as the neurosurgeon trained to do his.

Taxing Plastic Surgery In Beverly Hills

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Taxing American-Based Cosmetic Surgery

Here’s why the proposed 5% surtax on cosmetic plastic surgery is an insult to any thinking American.

Consider a cosmetic plastic surgery practice a business – which it is. 

Each doctor’s practice/business starts from zero.  To build a practice, we doctors first invest in ourselves by pursuing long and arduous training and education. Up to 15 years after high school! And for some of us, we added on a couple more years serving our country in the military.  But in order for the public to benefit from our skills, we need to have a place to work; we then invest further in the “bricks and mortar”. We build an office, to deliver our services – right here in America.

We borrow from American banks; construction and equipment loans. We buy equipment and supplies from American distributors.  We create jobs for Americans – administrators, nurses, medical assistants.  We utilize the services of American attorneys, accountants and practice management consultants. We don’t set up dummy headquarters in the Cayman Islands to evade taxes. We don’t communicate with our customer-patients from inexpensive secret call centers in Mumbai. We don’t earn our dollars by operating  Ponzi schemes out of Wall Street boiler-rooms.  

We grow our practices by providing quality service and good value.  We seek to be honest craftsmen. And, many of us give back to the community by teaching – without pay – at the local medical schools or Veterans Hospitals. 

That’s why it seems ironic that Congress has singled out a small but productive home-grown 100%-American industry –cosmetic plastic surgery — to levy an additional tax. Have we done something wrong besides being successful and making Americans’ lives better?

I wonder why these Washington economic heavyweights didn’t think about taxing multinational corporations that have huge incomes, much of which is garnered from operations outside the United States.  General Motors sells a lot of Buicks in China.  They are making a lot of money there.  All their sobbing about losing money in America was inconsequential to the bottom line of their financial statements.  Maybe they don’t make a profit here; it’s just being done with non-American labor far across the sea. How about a tax on foreign manufacturing by American-based companies? Wouldn’t that be fair?

There’s always hot air and hypocrisy from Washington, of course.  I guess the problem is that we cosmetic plastic surgeons and our patients don’t have the army-like lobbying force that GM and the other multinationals hurl into Washington. Seems Congress thinks it’s O.K. for them to siphon off jobs and money from the United States – and not pay any price.  Multinationals have more friends than we do. Even Nancy Pelosi, obviously a devotee of cosmetic plastic surgery, won’t speak up for us. Maybe her lips are paralyzed from too much Botox or Dysport.

Somehow, we cosmetic plastic surgeons will soldier on and somehow we shall still continue to serve Americans who want our services. Our practice, and I suspect others, has decided to absorb the tax ourselves and not further burden the patients. We shall “eat the tax”; just like our favorite camera store does to help keep traffic flowing and contribute to the fight against the recession.

Finally, unlike, GM we won’t ask for a government bail-out. Maybe we’re too proud to ask for handouts. We’re old-fashioned. We ask nothing from Washington, other than to be left alone and to use the talents we spent half a life perfecting. However, our doors are not necessarily open to everyone. We still have the right to decide whom to accept as patients. So, Senator Harry Reid, who concocted this legislative abomination, listen up: When you are bruised and battered by the health care reform debate, you will be shown the door and given a map to the Mexican border. There are plenty of medical clinics there. They will be glad to see you and there’s no 5% tax.

Dr. Oz and Dr. Linder Deliver a Great TV Segment To A National Audience

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Dr. Oz and Dr. Linder Deliver a Great TV Segment To A National Audience

Mehmet Oz, MD, has created an excellent television program that focuses exclusively on medical consumerism.   Dr. Oz who is a heart surgeon and Professor of Surgery at Columbia University Medical School in New York, has been a long-time favorite of Oprah.  He appeared with Oprah on 55 programs before launching his own television program which incidentally is co-produced by Harpo Productions, Oprah’s production company.

The Dr. Oz Show, on air for only six weeks, has already become the third most-watched television talk show. 

I have been impressed by Dr. Oz’s ability to clearly and graphically explain often complex medical issues to his audience.  He knows how to speak in words that all can understand, not medical-ese.   He is covering interesting and often controversial topics such as hysterectomy.  But with every program, there are always several “walk-away” conclusions and bits of salient advice for the viewer. 

On November 3, Dr. Oz aired an excellent segment that told a story of Becky Keenan.  Becky, a traveling carnival owner, had always been obese and lost 140 pounds via a gastric bypass operation performed in Houston.  Following that, Becky saw that she required some reconstructive plastic surgery because her breasts had, following the operation and subject to gravity, become very “hangy” and unattractive.  In addition, she had the typical “apron” of excess tummy skin literally hanging over her belt line.

Stuart Linder, MD, FACS, provided the answer to her sagging and hanging skin.  Using a standard breast reduction and uplift technique, Dr. Linder refashioned Becky’s breasts.  At the same time, a tummy tuck procedure erased the tummy overhang.

On the program, Becky recounted her history and showed a number of photographs as an always obese young person.  The program tastefully showed her postoperative results in one week which looked terrific. 

On the program, Dr. Oz and Dr. Linder clearly explained the technique involved with excellent graphics and animation.  It was very tastefully done and the viewer clearly understood the benefits of weight loss and the need and propriety for the reconstructive plastic surgery that followed. 

Whichever producer at the Dr. Oz Show produced the segment really hit a home run!

Care Package After Cosmetic Surgery in Beverly Hills

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     Care Package After Cosmetic Surgery in Beverly Hills

“Care Package” is a term very familiar to many Americans regardless of interest in cosmetic surgery.  The original Care Packages were donations of food and supplies to the poor of war-ravaged Europe, beginning in 1945.  Americans, the most generous people in the world, not only helped prop up devastated Europe through the economy-boosting Marshall Plan, but individual Americans sent care packages to share with the less fortunate in England, France, and even to our former enemies, Germany and Italy.

Today, 60 years later, in the world of cosmetic surgery, the term Care Package has now become common parlance for a kit that contains all the supplies and medications necessary for home care after cosmetic plastic surgery.  Since cosmetic facial surgery including rhinoplasty, with or without septoplasty and turbinate resection to improve nasal obstruction, face and neck lifting, eyelid surgery, chin augmentation, neck sculpting, liposuction and chemical skin peel, are outpatient procedures – not hospital procedures.  It is important that patients have all the needed supplies and medications, at hand, at home.

I have always felt that it is incumbent upon the cosmetic plastic surgeon’s office to provide as much guidance and support for the post-operative care as possible, regardless of where the surgery took place: hospital, outpatient surgery center or office operating facility. I stressed that in both my books, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON and THE ESSENTIAL COSMETIC SURGERY COMPANION.  For that reason, our home care package includes pain medication, antibiotics as appropriate, and all routine wound care supplies.  Such home care supplies would consist of nose sprays, both decongestant and refreshing saline or salt water. These are important after cosmetic plastic nasal surgery or functional nasal surgery including septoplasty and turbinate resection.  The kit has vitamin A&D ointment to be placed inside the nose to prevent crusting as well as small dressing pads placed under the nostrils to collect any drainage from the nose.

Dr. Kotler's post-op care kit given to his patients to take home after surgery

Dr. Kotler's post-op care kit given to his patients to take home after surgery

The Care Package for facelifting, eyelid surgery, chin augmentation and neck sculpture would include Q-Tips and ointment for application of the ointment to the incisions.   For chemical skin peel patients, there are additional supplies including special eye drops and large amounts of antibiotic ointment to be placed on the healing facial skin.

Procedure-specific written instructions are provided for each operation performed and are also placed in the bag.  Further, the patient has a listing of my home telephone and cell phone numbers so they can reach me immediately.

As I have always stressed to the young doctors I teach at UCLA and USC, the care of a surgical patient does not end with placement of the last stitch.

Beverly Hills Rhinoplasty Surgeon's Correction of the Pinched Nose Deformity

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Beverly Hills Rhinoplasty Surgeon’s Correction of the Pinched Nose Deformity

There are two means of correcting the pinched nose deformity.  Noses looked pinched or overdone because two much cartilage was taken out of the tip at the original surgery.  And, there are a few people who are born with this deformity.  In the case of the latter, the cartilages at the tip of the nose instead of being convex are concave. 

The solution is identical. Either cartilage is grafted or transplanted from either inside the nose or from the ear and placed underneath the skin over the existing cartilage or the pinch is corrected by incremental filling injections.

The decision whether or not to have surgery performed or use filling injections, which is an office procedure, must be made after a thorough analysis. If breathing is an issue and there are other deformities of the nose which cannot be corrected by filling injections, then surgery is indicated although often even after surgery, the filling injections are helpful to achieve an optimal result. 

I am very pleased with liquid silicone which is the permanent filling injection material.  On the cover of my book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON, you will see a young man who had very severe pinching on the left side of the nose.  While part of this overall unsatisfactory look was a deviated septum and poorly performed rhinoplasty previously, it was necessary to use filling injections on the left side.  The result speaks for itself.  Liquid silicone is permanent but must be injected gradually over a period of several months because it cannot be easily removed.

How This Beverly Hills Rhinoplasty Surgeon Corrects Asymmetric Nostrils

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How This Beverly Hills Rhinoplasty Surgeon Corrects Asymmetric Nostrils

Asymmetrical nostrils may present themselves before surgery.  That is why it is very important for the surgeon to conduct a very thorough evaluation and examine for asymmetries. More often than not, nostril assymetry is caused by a deviated nasal septum.  The septum, which attaches between the two nostrils, may be off-center and, therefore, influencing the size and shape of the nostrils. 

If the nostril asymmetry is caused by the deviated septum, then at surgery, correction of the deviated septum should correct the problem.  However, some people may have been born with asymmetrical nostrils.  Also, some people as a result of unpredictable healing after rhinoplasty, will have a difference in the nostril shape and size.

I believe the most practical, economical, expeditious and reliable technique to correct asymmetrical nostrils is to use a filling injection. The filling injection can be temporary such as Juvederm or Restylane or permanent such as medical grade liquid silicone.  The nostril that has the highest peak and largest size is filled to match the other side.

Interestingly, the eye recognizes asymmetries more than gross dimensions.  Therefore, it is very important that even though the nostrils may not be the perfect configuration then at least they can be made symmetrical to avoid detection.

Correcting A Short Nose Is A Common Beverly Hills Nose Surgery

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Correcting A Short Nose Is A Common Beverly Hills Nose Surgery

Revision rhinoplasty is common in Beverly Hills because there is a certain percentage of patients who are unhappy with their surgery previously performed elsewhere.   Here in Beverly Hills, where we have several surgeons with a long track record of experience and superspecialization, patients congregate to have the more the difficult nasal surgeries performed.

One of the more common consequences of an overzealous or overdone rhinoplasty is that the nose is “too short.”  The nose tips up and the angle between the nose and the lip is so great that sometimes it looks like the nostrils may fall prey to a thunderstorm.   Perhaps there was inadequate surgery done at the junction between the nose and the lip. This can be improved.  The nasal spine and the caudal septum, whether straight or deviated, may be altered and that sharpens the nose-lip angle. This makes the nose look much less pug or upturned.  If that is not an option, cartilage can be transplanted just behind the tip to push it forward.  Another technique is to use a filler to plump the skin of the tip just between the opening to the nostrils and this again leads to a more satisfactory nose-lip angle.  Also remember that a nose looks overly-short if the bridge has been taken down too much.  If the nose has that overdone ski-slope look, filling this defect either with a cartilage graft or even with office-performed filling injections will raise the bridge and make the nose look much less short. 

Understand that much of what we do has to do with illusions and appearances – small differences can make a big difference.