Nasal Exam

Regular readers of our blog posts already know a CPAP is a face mask and machine for people who snore, often due to problems inside the nose that block healthy breathing.

But, as a curious cosmetic plastic surgeon, we also scan forums and bulletin boards for news about CPAP (which stands for “continuous positive air pressure,” a fancy way of saying “forcing air into your lungs through your nose”.)

So we note some users have found that nasal surgery makes their CPAP work even better.

The basic start of all this is raw snoring….ear-splitting, freight train decibel, nocturnal snoring that makes the bedroom curtains flap in the breeze and can be heard downstairs, if not the next house.  Pity the sleep-robbed mates of snorers.

Snoring can have many causes but some of the most common are:

• A deviated septum
• Swollen turbinates, structures higher up in the nose

A septum is the thin wall of cartilage that separates your two nostrils. When bent, twisted or otherwise deformed, they can block the breathing channels in the nose.

Turbinates warm and humidify the air you breathe. But they often react to allergies and other conditions by swelling, again blocking healthy, quiet breathing.

Curious about the numbers of healthy and blocked breathers, The University of Washington’s Sleep Disorders Center studied 306 CPAP users for two years. They wanted to find why some did not wear the CPAP mask regularly. (Read more about nose surgery and CPAP use.)

After exams, 108 patients showed abnormal nasal exams and were also the same group who did not use the mask correctly, if at all. The study authors concluded patients with abnormal nasal exams had decreased CPAP use and tolerance.

Concluded the authors: why not treat nasal conditions before prescribing a CPAP?

Yet another study at the Stanford Sleep Disorders and Research Center in Palo Alto, California, found that turbinate treatments, when appropriate, appear to benefit nasal obstruction and ease the breathing of CPAP users.

But before you say “yes” to a CPAP, ask yourself if any medical professional has actually looked up into your nose to see and diagnose the state of your nose and if its internal architecture allows for easy, quiet breathing.

Perhaps that would be the best first step possible!

The function of the nose: to breathe

If you read plastic surgery bulletin boards and forums dedicated to people who have trouble breathing, you’ll discover that the real cause of their breathing woe is usually a surprise.

For instance, Kilgore T. writes: “I just had too many episodes of Afrin addiction due to swollen turbinates.”

(Background: turbinates are bony, flesh-covered structures high inside the nose. Turbinates often react to allergies and other “insults” by swelling and blocking healthy breathing.)

Afrin shrinks nasal tissues but has bothersome side effects like keeping you up all night because it’s an upper and causing mens’ sensitive tissues to swell.

The proposed solution to bugbear breathing: turbinate reduction surgery. Kilgore asks fellow bad breathing sufferers to:

• Comment
• Commiserate
• Share experiences about lousy breathing and internal nasal surgery.

Kilgore’s headline was: “Nose Surgery – CPAP usage and effect on apneas?” He’s asking if he would breathe well.

(Yet more background: CPAP, short for Continuous Positive Air Pressure is a machine that forces air through the nose and into the lungs; a CPAP is worn in bed at night.

Read more about CPAP and nose surgery.

Squid13 tossed in his two cents worth: “I had the surgery…they packed my nose with gauze for a couple of days and then removed it…in four to six weeks (the nose) good as new and boy did my breathing improve…make sure you go to a doctor who knows what he is doing, as too much turbinate reduction can lead to very deleterious results, i.e. empty nose syndrome.”

Added SleepingUgly: “I had septoplasty and turbinate reduction. It had great benefits to me (sic) in terms of being able to breathe through my nose…I have even gotten less sinus infections since the surgery.”

Commented Kitatonic: “(my doctor) stated nasal surgery should be done if the goal is to improve your daytime breathing.”

But Dale92 put a nice cap on Kilgore T.’s question: Pens Dale: “I had turbinate reduction on my right side and my deviated septum fixed in 2004. Before this, I was unable to breathe through my nose for most of my life except for periods of Afrin use which caused even more problems. Finally, I was able to breathe!…Like I said, it was the best thing I had ever done to improve my health…I would gladly do the surgery again.”

You can also have a cosmetic nose job during the same procedure.

(Read the internal nose surgery comments in full.)

CPAP User

If your eye caught the headline on this post, you are probably either a CPAP (Continuous Positive Air Pressure) user or your bed mate is one.

Joked one 50-something CPAP user after having internal nose surgery: “Only my ex-wife thought the CPAP was great; she considered it an anti-adultery device!”

You must admit, the typical CPAP user going to bed, like the guy above, looks like he (or she, in fewer cases) is ready for high altitude flight or suffers from some strange breathing disorder.

For those who don’t know, a CPAP forces air through the nose into the lungs. The device is diagnosed when a person snores loudly, depriving the body’s organs of enough oxygen. (And we mean ALL the organs!)

But in the vast majority of cases, an internal nose blockage causes the snoring. Fix the block and ditch the CPAP machine.

Of course, snoring can be cause by other health woes, including:

• Enlarged tongue
• Short, receding lower jaw
• Huge tonsils
• Enlarged palate or uvula, that bit of worm-like flesh dangling in the back of the throat

A common blockage is a bent septum, the thin wall of cartilage separating the nostrils. A deviated septum often rambles from one side to the other, restricting airflow.

Another major red warning flag: enlarged turbinates, bony, flesh-covered structures higher in the nose that swell in reaction to allergies and other unknown reasons. Solution? Trim the turbinates to ensure good airflow.

If you:

•    Snore
•    Suffer frequent sinus infections
•    Have allergy attacks or
•    Use a CPAP

ask yourself: when is the last time a doctor looked up into your nose? It seems like an elementary course of action but it rarely happens for whatever reasons.

Here’s another hint: top nasal surgeons say that healthy breathing is quiet breathing. If you can close one or the other nostril and, with your lips firmly sealed, hear noise while breathing through that one nostril, you may be a candidate for internal nasal surgery.

A competent nasal surgeon (who is also usually a cosmetic plastic surgeon) can perform the internal nose surgery you need, with or without a cosmetic rhinoplasty.

Concluded our pal from above whose wife though he looked not-so-sexy in his CPAP mask:

“My new partner tells me I sleep quietly and soundly; the CPAP mask and machine now sit off-duty, in its bag in a dusty corner of the garage.”

Before and After Rhinoplasty and Internal Nasal Surgery for Better Breathing

"Rip Hamilton and Nose Guard Mask

Now that the long-delayed NBA season is under way, we can’t help but notice at least one hard-charging basketball player who has been plagued with broken noses.

Rip Hamilton of the Detroit Pistons suffered three broken noses before he started wearing a hockey mask in the 2003-04 seasons.

Hamilton now wears a specially made nose protector (known as a “Rip Mask”) which has spurred calls from all over the globe. One 50-year-old guy in Hawaii addicted to pickup basketball games traveled to Detroit just to be fitted for one. A plaster cast of your face is necessary to get a “Rip Mask” nose guard.

(Look at ten other professional basketball players who wear masks due a once broken nose.)

Actually, a broken nose is the most common facial injury and a special bogeyman to all professional athletes who can’t – especially during an abbreviated season – take six weeks off, waiting for a broken schnozzle to heal.

Too often, an athlete decides to just tough it out. Then, the broken bones heal in place, usually creating a crooked or bent nose. That only doubles the athlete’s (and the plastic surgeon’s!) woe because breathing problems are created when air can’t move freely through the nose to the lungs.

Most people with a broken nose on the mend do not require a protective mask unless, like our basketball playing pal from Hawaii, a chance of hard contact to the nose is at hand.

The same rules apply during most cosmetic nasal surgeries. For instance, in order to narrow a nose, the bones must be realigned. Usually, the plastic surgeon uses instruments inside the nose to release the nose from its attachments and then, with the fingers, moves the bones into the desired position. In six weeks, the nose becomes fully healed.

Of course, there are no worries for the patient who does not plan on any:

• Boxing matches
• Getting in the way of swinging elbows attached to seven-foot athletes

Why so many broken noses? Among others, your nose is:

• The most prominent object on your face
• Nasal bones are the body’s thinnest and most delicate

How do you know if the nose is really broken? Look for some, or all, of the following symptoms:

• Swelling
• Sore to touch
• Bruises under the eyes
• Bleeding from the nose
• A different nasal shape
• Breathing is different

CPAP User Sleeping

We recently traveled by air and were herded through airport security with some basic items piled into those cafeteria-like bus boy carts for passage through inspection, including:

• Our shoes
• Pants that drooped to our knees due to no belt
• Our delicate, pricey laptop

We also noticed that quite a few men, who appeared over 50, had taken apart their CPAP (Continuous Positive Air Pressure) machines for inspection.

A CPAP is a small pump-like machine and face mask, used while sleeping. A CPAP forces air down the nose through a strap-on mask and into the lungs of a snoring person. Usually, a diagnosis of sleep apnea goes hand-in-hand.

Sleep apnea causes breathing to stop altogether and the person to wake momentarily.

Result? The CPAP puts plenty of oxygen into lungs and vital organs, allowing more rest. Bonus result: wives love the quiet that comes with no more snoring….once they get used to the whispering of the CPAP.

Thus, many who use CPAP machines have a blocked nose….. but don’t know it. The question is whether or not their blocked nose can be surgically repaired.

Many conditions may also cause snoring and sleep apnea, including:

• A thick or short neck
• An upper palate and or uvula (that worm-like extension that hangs down into the throat, above the back of the tongue) that needs reduction
• An unrepaired broken nose
• Deviated nasal septum, possibly from injury
• Enlarged nasal turbinates, sometimes the result of nasal allergies

After having seen over 4,000 patients for nasal surgery, we’ve noticed that many structures inside the nose that can cause:

• Snoring
• Blocked sinuses with a head cold or allergy attack
• Bonafide sinus infection, a serious condition,  requiring antibiotics and sometimes surgical intervention

One patient complained of loud snoring; when we looked into his nose and throat, we saw a huge uvula, hanging way down into the lower throat, swinging back and forth with each breath.

Result? Removing the uvula quelled the snoring. (Don’t worry, the uvula has no function; you can do nicely without it.)

Several key structures inside the nose need to be evaluated.

• The septum, the thin, vertical wall separating the two nasal passages
• The turbinates, shelf-like structures that warm, humidify and filter the incoming air.

If the septum has been broken and is crooked, it blocks incoming air.

The turbinates and nasal lining can swell due to cold viruses or allergies and contribute to reduced air flow through the nose.

A relatively short nasal procedure – done with or without cosmetic rhinoplasty – can:

• Correct breathing
• Stop the sleep apnea and
• Remove the need for a CPAP

Major hint: if your nose looks bent or crooked on the outside, it is also probably crooked on the inside as well. And not likely to allow normal breathing.

Without having to lug around that CPAP machine, just imagine how nice it would be to have one hand free to hold up your drooping trousers while going through airport security!

Childhood bullying

Last night, (October 11th) Nightline carried the story of Nicolette Taylor, a 13-year-old who been bullied, because of her nose which was broken at ages two and eight. She recently had a nose job to deflect the online and in-person bullies.
(Watch the Nightline plastic surgery segment).

While many decry children having plastic surgery, insisting that more effort should be put on stifling bullies. But the reality is: children and teens will routinely belittle and tease any child that looks even slightly different.

Consider the case of large, standout ears on a child. In all likelihood, that child will acquire the cruel moniker “Dumbo”. That usually causes the youngster to crawl into a shell and direct all his or her attention to the meanness in his life. Education becomes a distant concern.

That’s why most psychologists, educators and other professionals recommend pinning the child’s large ears back – in a surgical procedure known as otoplasty—before starting school at age five.

Likewise, a teen boy with big breasts – medically known as gynecomastia – has a tough row to hoe. Boys and girls will tease, ridicule and shame the lad for his feminine-looking chest. The cruelest cut of all: “No girl wants a boyfriend who has bigger boobs than her!” In many cases, the answer is male breast reduction performed by a plastic surgeon.

“Fair or unfair, we are judged by the way we look,” says Nicolette’s New York City plastic surgeon, Sam Rizk, MD, FACS.

Cosmetic plastic surgeons operating on teens want to know if:
• The teen really wants the surgery for him or herself
• A parent is pushing the child into surgery
• The teen is mature enough to comprehend and carry outpost-op recovery steps

According to the American Society for Aesthetic Plastic Surgery (ASAPS), rhinoplasty is O.K. when a nose has completed 90 percent of its growth. In girls, that can be 13 or 14.

Additionally, Nicolette worked as a child model and, post-surgery, is now attractive enough to model more.

To show the difference a cosmetic surgery can make in a youngster’s appearance, note the change in the teen pictured below. Her stand out ears made her an immediate target for teasing, ridiculing and bullying. But in the after picture, she has a more normal appearance which is important to teens because one of the leading desires at that time of life is fitingt into their peer group. Said one 14-year-old after otoplasty: “I wished I had not waited so long!” (After picture taken three months after procedure.)

Otoplasty, Before and After

After Rhinoplasty

Bachelor Pad’s Vienna Girardi (left) was pictured in late July at Los Angeles International Airport looking black and blue under and around the eyes. She made no secret of her July 15th rhinoplasty and wore a bandage over her recently rejuvenated nose.

A mere three weeks later, on August 8^th, Vienna was back on the job at the start of Bachelor Pad’s second season. About ten million people tune in for each episode of Bachelor, Bachelor Pad and The Bachelorette.

News reports have Vienna traveling from Los Angeles to Texas for her rhinoplasty. Of course, excellent plastic surgeons are found everywhere. But considering that Beverly Hills is usually considered the world Mecca of plastic surgery due to its large concentration of cosmetic plastic surgeons and nearby world class  teaching institutions, going from L.A. to Texas for a nose job is something like being in Newcastle without coal and traveling 1000 miles to bring the coal back to Newcastle.

Vienna’s new nose fits her face but she could have considered one thing about plastic surgeons: the surgeon who specializes in only five or six procedures will complete the surgery with less fuss and bother because he or she has done it so many times. For the patient, that means less bruising and swelling because the highly specialized surgeon disturbs less tissue. And that also means faster healing for the patient.

Vienna is widely quoting as saying she always felt like she had a “potato-head nose” and that she wanted to have rhinoplasty since she was nine or 10 years old. As with many school kids, there was cruel teasing and name calling, too; her nick-name was “Pinocchio”.

During her first TV appearances, bloggers favored the not-so-flattering, “horse-face”. So Vienna’s reasons are completely valid for having nasal rejuvenation surgery. In addition, any TV or movie actress knows the face can be the fortune.

According to news reports, Vienna had a nasal hump removed and the tip of her nose shortened.

A sense of self-confidence usually follows such procedures. Sure enough, Vienna tweeted about her surgery, “If it makes you feel better about yourself, DO IT.”

What do you think?

After Nose Job

Before Rhinoplasty

Before Turbinate Reduction

Many consumers of cosmetic surgery know about deviated septums, but many more write to nasal surgeons, asking:

• What is a deviated septum?

The septum — a thin wall of cartilage and bone inside your nose — separates your two nostrils. Many people have sinus-like problems and think perhaps their septum is bent or twisted and needs surgical repair.

For instance, one reader who thought he was plagued with sinusitis wrote to the famed Mayo Clinic asking about the cause of his inner nose woe. (Read more about the sinus complaint.)

Deviated septums are common – perhaps 75 percent of people have one.

Just because you seem to have sinusitis complaints due to a possibly crooked septum, there may be no reason at all to have nasal surgery to repair it.

Another common fact: true sinus infections are very bad news indeed. But facial pressure, clogged noses, and a dripping nose do not a true sinusitis diagnosis make.

If it really were sinusitis, you would experience:

• High fever
• Nausea
• Yellow, green or brown pus pouring out of your nose
• Vomiting
• Swelling and pain of the face

A diagnosis is made with certainty by x-rays or CT scans. Moreover, your doctor would sample the nose drainage and send a specimen to the laboratory to determine the cause.  The doctor would probably prescribe an antibiotic plus some heavy duty pain meds.

(Read more about actual sinus infections.)

The dead-bang giveaway: when patients tell rhinoplasty surgeons they have” three to four sinus infections yearly,” we know the cure may very well be found in structures, like the septum, inside the nose.

So what does the person do who frequently has:

• Congestion in the nose
• A dripping schnozzle that may also block up at night
• Snoring
• Sleep apnea

First step: have the situation evaluated by a head and neck (ear, nose and throat) specialist. Other medical causes may be responsible for your sinus-like symptoms.

And maybe your septum is bent or a little crooked. But it may not be the bugbear, after all.

Sometimes, the culprits and co-conspirators are a shelf-like structure inside the nose known as turbinates which can become enlarged.

Most often, turbinates enlarge from allergies. A badly deviated septum and enlarged turbinates are a troublesome duo and need to be managed if the patient is having breathing problems or sinus infections.

If your plastic surgeon thinks a deviated septum is responsible for your nasal troubles, the surgical repair of the septum is known as septoplasty. Not to worry, the surgery is done inside your nose, leaving no surgical scars at all on the outside.

And, be sure to ask if the turbinates need “a little off the top”.

After Rhinoplasty

After performing somewhere around 4,000 nasal surgeries, we’ve learned that a nose which is crooked on the outside, most likely needs some surgery inside the nose too.

In the vast majority of cases, cosmetic surgery to straighten the outside of the nose almost always needs some extra surgery on a vital part inside your nose – the nasal septum, a thin wall of cartilage separating the nostrils.

That wall must run straight down the middle and not turn to one side or the other. If it does, one or both sides of the nose can be blocked, and lead to a number of pesky symptoms like:

• Bad breath
• Dry mouth
• Sleep apnea
• Sinusitis
• Sinus infections
• Problem nasal congestion

Complicating the issue: symptoms come and go and are always worse with colds or allergies.

If decongestants, antihistamines and cortisone sprays don’t provide relief, you may want to consider septal surgery, the procedure that straightens a bent nasal septum.

Also required may be reduction of internal nose structures known as turbinates. The size of those structures interferes with normal breathing and sinus function. (More about that later.)

Sometimes, it’s a case of doing two birds with one stone. If you only want a straight nose, the first thing a rhinoplasty surgeon must do is correct the supporting structures inside the nose. Otherwise, the nose would still be bent.

Some tweaked noses have been present from birth while the others are caused by injuries. (Read more about blocked noses.)

Don’t sweat the scarring. Rhinoplasty and septum repair are done inside the nose with no scars.

Some patients have been known to put off or even reject doing these nasal surgeries due to something known as nasal packing. (It has nothing to do with suitcases!)

Let me explain:

After rhinoplasty — or any internal nose surgery — cotton packing is placed inside the nose for one to five days to:

• Absorb any bleeding
• Deliver important medications to reduce bleeding
• Minimize the chance of infection and promote rapid healing

But, here’s the rub: For the patient, nasal packing creates total nasal blockage and allows mouth breathing only. One patient said nasal packing made him feel like he was drowning because he could not breathe normally.

For everybody’s comfort, we now place a small nasal airway tube inside the nose and then place the packing around it.

Results?

Great healing while allowing more patient comfort.

(Read more about the Kotler nasal airway used in nose jobs.)

Lady Gaga

Despite the scarcity – and clarity — of before and after rhinoplasty pictures, word continues to spread that 25-year-old entertainer Lady Gaga, whose real name is Stefani Joanne Angelina Germanotta, has had rhinoplasty. (Check out the grainy, supposed before and after rhinoplasty picture of the songstress at the end of his post.)

Being of Mediterranean descent, her natural nose could have been larger with a hump as some Italian noses will.

And she does seem to be sensitive to how she was born, given the passion and general popularity of her hit tune, “Born This Way.” Gays and lesbians quickly picked up on the theme although Lady Gaga was at first obviously talking about people who wanted a change in some aspect of their facial or body appearances.

Moreover, in Lady’s Monster Ball Tour, Stefani gives additional clues about a nose, or other features, that could have been subjected to cosmetic or plastic surgery: “When just starting out,” she recalls, “I went on many, many casting calls for various jobs but was frequently turned away because I looked ‘too ethnic.’”

Did she mean her nose? Hey, who cares now? With one of the best voices in pop since Madonna, Lady could drop the outrageous costumes, just sing and still have millions of fans. If she did have rhinoplasty, it was bold move because some singers – like Barbra Streisand – won’t change the shape of the nose because they mistakenly claim it might affect the sound of the singing voice.

In May, 2011, Stefani gave an interview in England saying she would consider cosmetic surgery and is not totally confident with her body at the moment.

Nonetheless, she told Harper’s Bazar during the same month, “plastic surgery is promoting insecurity.” Well, okay, given the fact that cosmetic surgery acts to boost self-esteem, it seems like a mixed message.

Anyhow, we leave you with one of the few Lady Gaga nose job before-and-after pictures known to exist for you to decide. (Also note, it’s not a medical before and after pictures. We’ll tell you more about proper medical before and after plastic surgery pictures in a separate post.)

What do you think? Did she have a rhinoplasty?

(Meanwhile, look at a typical Mediterranean nose job before and after picture.)

Before and after rhinoplasty?