Septoplasty Specialist

Posted on April 22, 2010 by admin

Specialist in Septoplasty Surgery

Internal nasal surgery to correct a deviated septum is called septoplasty. The root words are “septum” which means partition and “plasty” which means changing form or shape.

The object of a nasal septoplasty is to correct a deformed, crooked or perhaps broken nasal septum which is blocking the airway. The end game is to make it straighter with fewer curves, baffles, angles, all of which contribute to blocking the airflow.

It takes considerable skill and dexterity to do an operation entirely through the nostrils. One has to conduct the operation with the same steps that are done in any operation: There is an incision, there is work that has to be done, then the wound has to be closed and stitches placed to assure satisfactory healing. Yet all this must be done through the nostrils; as if the surgeon is operating through a keyhole. Often the nasal septoplasty is accompanied by reduction of the turbinates. The turbinates, numbering three within each nasal passage, add to the surface area of the nasal interior and, therefore, multiply the humidification, purification, and warming functions of the inside of the nose. Some turbinates become too large, particularly the inferior turbinate, or lowest turbinate, and when the turbinate becomes enlarged from allergy or even other unknown stimuli, it is necessary to reduce the size. This can be done by many means, including standard surgical excision or laser treatment or other means to reduce the bulk.

Since airflow through the nose is related to the fourth power of the radius of the air passage (Poiseuille’s law, well known to students of physics), a slight increase in the functional diameter of the nose by relieving the blockages yields a huge differential increase in air flow.

It behooves the patient who is consulting for cosmetic nasal surgery to ask the surgeon to evaluate the breathing. It makes sense to correct the blocked nose at the same time that one is having cosmetic nasal surgery or rhinoplasty. Why not have two operations at the same sitting with one anesthetic and have the economy of one recovery period and, often, you can save considerable money since the second and third procedures when added on to the primary procedure are generally significantly discounted by the surgeon’s office.

Sinus Infections and Septoplasty

Posted on April 1, 2010 by admin

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.

Rhinoplasty or Septoplasty?

Posted on March 25, 2010 by admin

Complete Nose Blockage

There are some people who almost have no need for their nose. They are not using it to breathe. But if so, something is wrong. Nature gave us a nose for a reason. We are not supposed to bring air into our bodies through the mouth; the nose is the preferred route. Long ago, it was established in laboratory experiments, that lung function improves when the air is delivered to the lungs through the nose rather than through the mouth.

So what are the reasons for this complete nose blockage? There are a limited number of reasons why the nose does not allow enough air through it. The first is that the passages are blocked from a previous injury. When the nose is injured, the support structures cave in, become crooked and become an impediment to airflow. The nasal septum is broken, crooked, deviated. Often the injuries occur when we are young and so the adult patient has no knowledge of “normal breathing.” They have only known complete nasal obstruction.

Another common reason is nasal allergy, particularly when it is superimposed upon an architectural deformity such as uncorrected broken nose. The lining of the nose is very sensitive to certain allergens in the air. For some people in springtime it is grass and trees. For others it is indoor mold. Others have very specific sensitivity to ragweed pollen which only grows in certain parts of the country. But whatever the offending allergens, the nose blocks up because the lining swells. Two normal structures within the nasal passages called the inferior turbinates are particularly subject to this. The two inferior turbinates are larger than the four other turbinates can expand to nearly twice normal size. Such a blockage within the nasal passages has dire consequences for breathing.

If you combine a deviated nasal septum as part of an uncorrected nasal fracture or just because one was born with it, with nasal allergies causing swelling of the lining and particularly thickening of the inferior turbinates, you have the setting for very poor breathing.

There is good new about this sad story, however. Modern techniques of surgical correction sometimes in concert with certain simple medications can make a huge difference. One of the most rewarding things for a surgeon is to give a patient his breathing back. And, incidentally, when you give the breathing back, you also give the sense of smell back. Because if air does not enter the nose, the smell receptors high in the nasal passages are not activated and the sense of smell is non-functional. People think that taste comes from the tongue in the mouth but the reality is that the tongue has very primitive sensors that detect only salt, sweet and bitter. But the actual aroma of food, for example, comes when air passes through the nose and stimulates the olfactory nerve which carries the sensation of smell to the brain. Now you know why “food does not taste very good” when you have a cold. Colds are temporary. Think about those people who have permanent blockage and never have the pleasure of smelling a blooming rose or even a great dinner dish.

Los Angeles Rhinoplasty

Posted on January 27, 2010 by admin

What’s With the Five Hour Rhinoplasty?

I am hearing some amazing stories from patients. While we always learn from listening to our patients, I am not only learning but becoming a bit dismayed with respect to what I am hearing about nasal cosmetic plastic surgery. Patients report operations taking three, four and even five hours that ultimately were unsatisfactory for the patient. It seems the operations become longer as more grafting and transplantation of tissue takes place. Now certainly there are indications for adding on tissue into the nose, particularly if there has been previous surgery or if there has been an accident that has destroyed some of the tissue. But, even if that is the case, why are these operations taking so long? I am not sure of the answer, except, my sense is that some surgeons are making the operation much more complicated and complex than need be. For many of the grafting or transplanting needs, there is adequate tissue inside the nose itself. This of course makes it very economical and efficient to be able to harvest the tissue since it is coming right from the area that we are working on. Often, we use cartilage and bone from the nasal septum because we are taking it out anyway to correct the deviated nasal septum and improve the airway, and correct problems that might lead to sinusitis and other serious complications. While only very rarely is it necessary to take cartilage from the ear, I am now hearing stories of almost routine harvesting of rib cartilage and even rib bone to be place inside the nose, and of course, that makes for a very involved, complicated and long duration operation since other surgical sites besides the nose must be operated upon. I guess I am just from the old school. We do nearly all our surgeries from inside the nose using completely hidden incisions, closed with absorbable stitches. That is called a “closed rhinoplasty“. The “open rhinoplasty” requires an external incision, and I just don’t see the need for that very often. And I have done over 4,000 cases in my career which now spans nearly forty years. The other issue is that some surgeons are not efficient. It just takes them too long to get the job done. I would attribute that to less-than-optimal training in the residency programs as well as inexperience. Generally, inexperienced surgeons are slower than veteran surgeons. The “occasional nasal surgeon”, the doctor who spends more time doing other cosmetic plastic surgeries such as breast augmentation, tummy tuck, breast reduction and liposuction just doesn’t develop the facility for rhinoplasty because he doesn’t operate on the nose often enough. He cannot become a master nasal surgeon. In my experience, most cosmetic nasal surgery or rhinoplasty procedures could be done within an hour. If you need to add on the functional or breathing operation, that adds another 20-30 minutes. The total time in the operating room, including going to sleep and waking up from the anesthetic, should rarely be more than two hours.

Rhinoplasty Prices in Beverly Hills

Posted on January 14, 2010 by admin

Has the Recession Affected Rhinoplasty Prices in Beverly Hills?

The recession has affected nearly every business, industry and profession in the United States – including Beverly Hills. While Beverly Hills remains a cosmetic plastic surgery destination for many people from the United States and throughout the world, the reality is that in a recessionary environment, fees are reduced.

However, it is important to understand that a low fee by itself should not be the decision-making factor when considering having cosmetic plastic nasal surgery. The price range of rhinoplasty encompasses both the less experienced, younger practitioners and the veteran superstars and super specialists of the cosmetic surgery world.

It is accepted that young doctors, eager to build their practices will charge less for their services and hope to attract patients in that manner. For patients, there sit risks. Because, often, the younger surgeons do not have the talent and long line of experience to handle anything but the most simple case.
But, few nasal plastic surgery cases are simple. Often, there are breathing or sinus problems that should be corrected. Nasal septoplasty and turbinate resection to improve the airway should be considered in such cases. Does the young surgeon have the training, talent and experience to handle all those issues?

The reality is that rhinoplasty fees in Beverly Hills may be higher than they are in Omaha, Nebraska or Oshkosh, Wisconsin, but of course, that reflects the cost of doing business including rent, salaries, etc.

One should always inquire from the office as to what the cost of the rhinoplasty is and to ask if, in fact, there are some ways to be granted a courtesy. Don’t expect to get a courtesy reduction in the fee just for asking, however, because that is not likely. What will help you get a reduction in the fee is being able to schedule your case at the time that is convenient for the outpatient surgery center and the surgeon’s office. That is the most common and proper reason for fees to be reduced.

Remember that rhinoplasty prices also reflect the complexity of the case and the time involved in performing the surgery. Particularly, if you need revision rhinoplasty in addition to that septoplasty and turbinate resection to help you breather, the fee will be higher than that for just shaving a bulbous tip.

Beverly Hills Nose Job Problems

Posted on December 31, 2009 by admin

“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.

Cocaine and Rhinoplasty in Beverly Hills

Posted on December 15, 2009 by admin

Cocaine and Rhinoplasty in Beverly Hills

Unfortunately, cocaine use is still with us. There are significant consequences to cocaine abuse. The worst complication is its effect on the heart and blood vessels which causes high blood pressure that can possibly lead to a stroke – or even death.

Cocaine and Rhinoplasty Surgery Do Not Mix!

With respect to nose surgery in Beverly Hills, patients who have been abusing cocaine present significant surgical problems. First, the lining of the nose is terribly inflamed and irritated and it is impossible to conduct a proper operation under those circumstances. Secondly, the abuse of cocaine can lead to creation of a hole within the internal partition of the nose. This is known as a nasal septal perforation. The hole can be anywhere from the size of the tip of a fountain pen to the size of a nickel.

There are problems that come with septal perforations: crusting, whistling and bleeding. It is a real hassle. And once that hole is created, it is very difficult to surgically close it. While there are some appliances that can be inserted to act as a “stopper,” just be aware that one is asking for considerable problems with long-term cocaine abuse.

The other issue is that one should never consider having any cocaine in their body at the time of surgery. This sets the stage for a possible anesthetic catastrophe! There can be an unfavorable interaction with the anesthetic drugs as well as the local anesthetics that must be injected.

Remember, doctors are not judges. We are not an arm of the legal system. Our conversations and records are private and cannot be shared with anyone without your permission. We don’t have an editorial position on personal choice issues. Our only job is to serve you. However, you need to be frank and honest with your doctor whose only aim is to have a safe surgery and a satisfactory outcome for his patient.

How Important Is It to Focus On Whether the Beverly Hills Cosmetic Surgeon Performs An “Open Rhinoplasty” or “Closed Rhinoplasty”?

Posted on November 25, 2009 by admin

How Important Is It to Focus On Whether the Beverly Hills Cosmetic Surgeon Performs An “Open Rhinoplasty” or “Closed Rhinoplasty”?

I find patients often get hung up on technical details that have little bearing on the outcome.

Because of attention given to the so-called “open rhinoplasty” in recent years, it seems to have captured the imagination of the public. The reality is that for over 75 years all nasal surgeries were done by incisions entirely within the nose, the “closed rhinoplasty” approach, and results were generally good.

I understand the value of an open rhinoplasty as a technique to teach young surgeons but once they have mastered the fundamentals of cosmetic plastic nasal surgery, they should be able also to perform the operation from within the nose. Yes, it is a bit easier to see the structures of the tip when an external incision has been made and the skin has been lifted up, akin to lifting the hood of a car. However, there is always some price to be paid when additional incisions and maneuvers are fashioned. For some people, the scar is visible and that turns out to be a point of dissatisfaction. There is a slight increase in swelling after surgery and this could translate to longer healing times.

In my opinion based on nearly 40 years and 4,000 nasal surgeries performed, the great majority of the noses can be satisfactorily done through hidden incisions entirely within the nose, closed with absorbable stitches.

You've Had Fillers In Your Nose. Can You Have a Beverly Hills Rhinoplasty?

Posted on October 23, 2009 by admin

You’ve Had Fillers In Your Nose. Can You Have a Beverly Hills Rhinoplasty?

The first question is, “Which fillers?” If you’ve had temporary fillers such as collagen, Restylane, Juvederm or Sculptra, you might wait for these to dissipate before a final decision is made with respect to rhinoplasty or cosmetic plastic nasal surgery. As a matter of fact, it is advisable because a surgeon should not base his decision on the temporary appearance of the nasal structure.

Dr. Kotler's Non-Surgical Rhinoplasty Patient

If you’ve had a permanent filler such as medical grade liquid silicone or even ArteFill or Radiesse, this can present a technical challenge for the surgeon. He is going to have to “plow through” tissue that has had a filler injected into it and has developed a fibrous or scar tissue reaction to the filler which is responsible for the filler’s maintaining its position and appearance.

It is very important that the surgeon knows what material was used. If necessary, the medical records should be retrieved.

I would advise patients considering using fillers to first ask themselves if they have not given any consideration to the rhinoplasty. It is always wise to do the rhinoplasty procedure – with or without nasal septoplasty and turbinate resection for breathing – prior to any placement of filling material. I like to think of the fillers as the dessert or “topping off”: they can be used to correct any minor imperfections so that in the end, the patient gets the result closest to their wishes.

Disposable Stitches For Beverly Hills Nasal Surgery

Posted on October 15, 2009 by admin

Disposable Stitches For Beverly Hills Nasal Surgery

Nasal surgery can be performed either as an open rhinoplasty or closed rhinoplasty. Open rhinoplasty implies that there is an incision made on the nasal exterior between the nostrils and sometimes at the junction of the walls of the nostrils and the cheek in addition to internal hidden incisions. Closed rhinoplasty is the title for a cosmetic nasal plastic surgery that is done entirely through hidden incisions within the nose. The choice of surgical incision approach depends on the experience and training of the surgeon. Excellent results can be obtained by either procedure in the hands of the skilled, experienced surgeon. My observation is that those surgeons who have been in practice longest, who have the largest case volume, the greatest experience and highest degree of specialization – the superspecialists – favor the closed rhinoplasty.

Closed Rhinoplasty Performed by Dr. Kotler

In open rhinoplasty, the incision may be closed with what are known as “permanent” sutures (stitches). Permanent is a misnomer; these sutures unless those placed internally into a body cavity such as the abdomen, are not permanent; they have to be removed. But in closed rhinoplasty, since all the incisions are placed on the interior and would be more difficult to remove because of their hidden location, absorbable or “disposable” sutures are placed.

There are a variety of sutures which may be used, everything from synthetic, man-made sutures, to sutures known as “catgut” or “gut”. Such sutures are processed from lamb intestine. Catgut sutures treated with chromium are known in the surgical world as “chromic sutures”. Such immersion in chromium allows the sutures to resist digestion longer and thus remain longer to encourage healing.

Suture selection is made depending on the desired duration of the stitches holding the tissue together or closing incisions. For some particular cases, say tummy tuck, it is important to have the stitch stay in place for several months until strong internal repair tissue is formed. Typically for closed rhinoplasty incision closure, five to ten days of presence is adequate. The process of dissolution of the sutures is automatically performed by the body. It silently attacks and digests them since they represent a foreign material. The process is hastened in a moist atmosphere, hence the reason to use the saline or salt water nasal spray after cosmetic nasal surgery or reconstructive surgery such as nasal septoplasty and turbinate resection to correct nasal obstruction. Likewise, the A&D ointment when placed inside the nostrils will keep the stitches remaining soft and less brittle-like and, therefore, better tolerated by the patient.