Category Archives: Rhinoplasty Specialist

Sleep Apnea on the Rise

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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

 

 

Considering Rhinoplasty?

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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.

 

Rhinoplasty Packing Anxiety

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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.

Rhinoplasty Cost

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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. 

 

Revision Nasal Surgery

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Discussion of Revision Nasal Surgery

Nasal surgery is an art based on a science, but it is not magic.  As a surgeon, I can only work with what I have been given with respect to tissue characteristics following previous surgery.  The aim is often to improve both appearance and function, and; therefore, there is a challenge introduced when the operation is not the first visit to the tissue.

I want to urge a sense of realism on the part of what the expectations could be.  We always attempt to yield the very best result possible with respect to both breathing and appearance.  So, while maximum improvement is always the surgical goal, and is, indeed, very often attainable, improvement is not the same as perfection.  The reasonable aim is to deliver a nose that is natural in appearance and functions well.

Please understand that in contrast with both primary nasal surgery, or original nasal surgery, the final result takes a bit longer to present itself.  Not that you will look terrible.  It is just that the swelling, although not necessarily highly visible to anyone, just takes a bit longer to subside.  Some noses look very good in 3-4 weeks, and others need more time for maturation.  As one patient said, “I guess it’s sort of like fine wine.  It takes a little time to get to its best.” That is true. 

After Surgery

After the surgical session, it may be important to undergo minor improvements at the postoperative office visits.  We have long experience in the use of medications that can be used to “smooth out” any irregularities or imperfections.  Another class of medication is used to help reduce internal scar tissue and unwelcomed thickening of the skin.  These are the medications that are called “shrinkers.” 

You and I make the decisions, jointly, before committing to any of these treatments.

For more information, please consult our website dedicated to revision nasal surgery at http://www.revisionrhinoplastydoctor.com/.

Middle Eastern Rhinoplasty

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Noses are different within the varied ethnic groups that populate the planet.   An Asian nose has certain features which distinguishes it from the Northern or Central European nose which is different than the Middle Eastern nose which is different than the Central American nose.  One’s color which is a reflection of racial ancestry has an influence also irrespective of the geographic location.  For example, Asian patients regardless of where they dwell in the world, typically have a broad nose with a low bridge and wide nostrils with thick nostril walls.  These are racial characteristics.  Due to intermarriage, often certain features are improved or worsened depending on the genetic match.

Rhinoplasty or cosmetic nasal surgery for Middle Eastern patients must take into account the following typical features of the nose:  There is usually a bump or hump.  The nose tends to be long and somewhat curled down.  When smiling, the tip of the nose drops down even further.  The nose may be wide with very broad lower cartilages causing large nostrils.

The management of such noses has to be very judicious.  It is important to remove the bump without causing a scooped-out appearance.  The nose should be narrowed but never pinched.  The tip needs to be raised up such that the nose no longer seems like it is going to touch the lip when smiling.  And, speaking of smiling, the little muscle that causes the tip to depress with smile generally has to be severed.

The ideal result would be a nose that has not been made too small, is not turned up too much and, as noted earlier, does not have a scooped bridge or a pinched tip. Improvement with preservation of ethnic identity is the key to success. 

Rhinoplasty Mishaps

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Arched Nostrils

Arched nostrils refers to a rather strange appearance to the nostrils that typically follows somewhat overzealous cosmetic nasal surgery or rhinoplasty.  There are some people who are born with this but that is quite rare.

Understand that typically nostrils are essentially oval.  Depending on the ethnic group, the plane or disposition of the oval may be horizontal or somewhat oblique.   For example, Asian people typically have rather wide nostrils that are oval but sit very much in a horizontal plane.  Most Caucasians’ nostrils are also oval but sit somewhat obliquely.  Occasionally people have round nostrils.  However, the arched nostrils have an inverted V configuration at the top.   That is a tip-off of nasal cosmetic surgery and there may be other visible tip-offs.

Why does this happen?  It happens when too much of the lowermost nose tip cartilage is removed.  When too much of it is removed, in the healing process, the existing cartilage “rides up,” elevates away from the previous position and pulls the nostril skin edge with it.  So what you are really seeing is a tenting up, if you will, of the upper edge of the nostril as nature’s contraction forces exerted themselves during the healing process.

Now you will ask:  “What can be done?”  There are two approaches.  One is surgical.  The surgeon can take a small piece of cartilage from inside the nose or even from the ear and implant it at the edge of the cartilage and at the edge of the nostril, through internal incisions, and, therefore, in a sense replace the cartilage that was lost and allow a more normal anatomy as this cartilage graft or implant fills out the tissue that was dragged upward.

The second approach is using a filler.  Temporary or permanent fillers can be injected at the very peak of the arch and by filling the soft tissue just underneath the skin, it will also “drive down” that edge.  It will force it down and change the configuration from an inverted V to be consistent with the general oval shape of the nostril.

Understand that problems that occur after rhinoplasty as nature exerts its healing are most commonly due to overzealous removal of either bone or cartilage.  The natural nose, where cartilage removal has been judicious and never radical, rarely shows any telltale signs such as arched nostrils. 

 

Rhinoplasty and Septoplasty Clinical Trial

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The Exciting New Postoperative Nasal Airway Clinical Trial

Our practice is very excited about a clinical trial that we are currently conducting. Nearly three years ago we developed a concept that we felt was very important for patient comfort and safety after rhinoplasty, septoplasty and turbinate resection and sinus surgery. The driving theme is that patients should be comfortable after these surgeries and be able to breathe immediately upon awakening from the anesthetic.

That does not sound too revolutionary but the fact is the operation has been done for 100 years and is typically accompanied by the nose being “packed” after surgery. What that means is that cotton or gauze-like material is placed within the nasal cavities after the operation to hold the reconstructed tissues in place and be capable of reducing the chance of nosebleed. These packings may also be used to deliver medications to the interior of the nose. So the rationale for having the packing makes sense, but from the patient’s standpoint, it is no fun because they cannot breathe. One patient described the experience as “like having a clothespin on my nose for five days. I was miserable.”

Patients complained about dry mouth, discomfort, difficulty sleeping and even anxiety. Another patient said “I felt I was drowning. I couldn’t catch my breath!” Sometimes we had to prescribe anti-anxiety medications like Valium.

It was in September, 2007, that it dawned on me that perhaps we could do better. Through a very prompt evaluation, we determined that it was possible to seat drinking straw-like soft plastic nasal tubes on the floor of the nose at the end of the formal operation, and pack the nose as indicated. The tubes would allow the patient to breathe through the nose, the preferred and normal channel, immediately after the surgery and during the first five or fewer postoperative days. Over the last three years, we developed variations in the design, all with patient comfort and safety in mind and recently were awarded clearance by the FDA to make the airway tube available to other doctors.

In our practice, 70 patients accepted our offer to have the tubes placed at the time of surgery and of those, 67 were extremely pleased and laudatory. The last phase of our research included cases where patients volunteered to be part of our clinical trial whereby only one of the two nasal passages would have the soft latex-free silicone tube placed. Therefore, in keeping with standard medical research standards, the side without the tube -completely packed – acted as the “control.” The tube side was the so-called “test” side. To date, we have had nine patients undergo that experience as part of the clinical trial and all nine agreed that they had a happier experience on the side that had the tube in place.

We have just about wrapped up the clinical trial and are about to present our work to the medical profession. To the facial plastic surgery, plastic surgery and head and neck (ear, nose and throat) specialties, who perform these procedures. Our research study will be submitted to a peer- reviewed medical journal for publication that will reach specialists world-wide.

Based on the result of our research study, we have proven that we are going to be able to afford our patients a more comfortable and anxiety-free post-operative experience. Next, will also make this airway device available to other doctors to also avail themselves of the opportunity to provide a better post-op experience after surgery.

With advances in modern technology, newer diagnostic tools, such as limited, simpler CAT as making it easier, more practical and less expensive to make the right diagnosis for those with blocked breathing, lessen their allergy symptoms, control snoring and sleep apnea and help free them of the plague of multiple sinus infections. To facilitate more successful and safe nasal and sinus operations, impressive high-devices and instruments are coming on-line.

Once again, Science Never Sleeps.

Dr. Kotler Nose

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The Dr. Kotler Nose

Patients always kid me that they want a “Dr. Kotler Nose.”  When I ask them what they think a “Dr. Kotler nose” is, they usually reply “Well, one that looks natural.  It seems that you have the knack of producing natural noses.”

I am flattered by that.  I also take pride in those observations, because that has always been my aim.  I want to deliver a nose that looks natural, as if the patient had never had nose surgery. As if the patient were born with it.

The opposite of a “Dr. Kotler nose”, or a natural, un-done nose, is one that looks unnatural, fake, and over-done.  The nose that is too scooped out, that is too narrow, that has a pinched tip that has an overturned tip such that one is looking directly into the patient’s nostrils.  No one wants the unnatural nose.  We all understand that.

Incidentally, “The Dr. Kotler Nose” is worn by Dr. Kotler.  I had my nose done.  It was done by the world- renowned, and first rhinoplasty superspecialist, Dr. Howard Diamond, in New York City, in 1980.  Dr. Diamond was the unquestioned heavyweight champion of the world when it came to doing cosmetic nasal plastic surgery. He was one of my principal teachers and mentors.

I have a set of my pre-operative photos in the office, and I am always willing to share them with patients so they can see what I looked like “before”.  I like my nose because it looks natural, fits my face, and it is a better nose than I had.  That is the definition of success.

Revision Rhinoplasty

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Rhinoplasty Revision – Is Simpler Better Than Complex?

Recently we saw a patient who was a student at a local university.  One year ago he had rhinoplasty performed and was very unhappy with the results.  He certainly had ample reason to be dissatisfied.  The nose was just terribly unsightly.  It was crooked, asymmetrical.  There was a gouge on the left side.  It had been over-shortened, overdone, and had entirely changed his ethnic appearance.  He brought in photographs to show me what he looked like prior and it was shocking how radical the change. Very poor judgment and substandard craftsmanship by the surgeon

I told the patient it was my opinion that much of what he disliked could, in fact, be improved without surgery.  By using a combination of filling injections and perhaps some shrinking injections, that he would have a much improved nose which would have a better “fit” with his ethnicity.  The common denominator was that, at his surgery, too much was done.  And when too much is done, often the most practical answer is to use filling injections under the skin to essentially plump up the skin. To replace the over-removed portions of bone or cartilage underneath the skin. The results of the injections resemble the results of having  surgical procedures which would involving grafting or transfer of tissue from one part of the body to the other. Often, in such complicated revision rhinoplasty cases, there may be more than one operation necessary to achieve a satisfactory result.

The patient was a little incredulous that I thought that I could achieve a satisfactory result –without any surgery – so I then did a “saline demo.”  We inject sterile saline, the same solution in intravenous fluids, underneath the skin that mimics the result of the final permanent filler injections. It made an amazing difference.  The nose was not perfect.  I would have liked to have seen some minor changes otherwise but they would require surgery.  But to achieve an 80% or 90% improvement without having surgery is impressive. And, practical and inexpensive compared to one or more trips to the operating room.

The patient related to me that he had seen another surgeon who told him he would require a seven-hour reconstructive surgery and that cartilage or bone would have to be taken from his chest and transplanted or grafted to the inside of the nose.  Disregarding the cost and the duration of surgery and all the other inconveniences and burdens, the question is whether or not the end result would be satisfactory.  Often, transplanted tissue can shrink or twist or partially disappear and this adds another level of complication and the need for even further surgery.

I think there is a place for simplicity that when an office procedure can do the work of surgery, it should certainly be considered. It’s not always the only treatment that is needed, but injections can do much of the work.

Before the operating time is reserved, the patient’s common sense might say: “Why not?”. Because there is great value to simplicity, economy and predictability.