Sleep Apnea on the Rise

Posted on April 20, 2011 by admin

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

ALLERGY DRUG, NOW FDA APPROVED, PROMISES BETTER BREATHING

Posted on April 8, 2011 by admin

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

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

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

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

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

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

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

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

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

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

~ Robert Kotler, MD, FACS

NEVER UNDERESTIMATE THE IMPORTANCE AND VALUE OF AN ANESTHESIOLOGIST

Posted on March 10, 2011 by admin

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

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

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

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

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

Dr. Kotler Nose

Posted on October 7, 2010 by admin

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.

Unhappy with Your Cosmetic Surgery?

Posted on August 13, 2010 by admin

What Do You Do If you Are Unhappy with Your Cosmetic Surgery?

Some patients will not be satisfied with their cosmetic surgery. In many cases, their dissatisfaction is warranted; in other cases it is not – the patient may not have been realistic about what results could be achieved.

In any event, the dissatisfied patient has the right to have a detailed conversation with her or her surgeon and ask why things did not go well and what can be done to improve the situation. I also believe a second opinion, from an objective outside source – ideally a superspecialist in the procedure – is extremely valuable. I always make this recommendation: “When in doubt, seek a second opinion.”

I have had occasion in my practice where neither the patient nor I were completely satisfied with the result. He is what I say to the patient, “Frankly, I’d like to have some input from a colleague and get an opinion as to what the best step would be going forward.” Patients very much appreciate the offer. I see to it that there is no charge made to the patient for that. And often the patient and I both learn something. All this is done in the spirit of preserving a good, solid professional relationship, with the object being to have a satisfied patient and a gratified surgeon.

One thing that is very important is that the consulting doctor have access to all the medical records including pre-and post-operative photos. Remember, regardless of the state of friendliness between the patient and the original surgeon, the surgeon is obliged to provide these records to the patient. Medical ethics, and state laws governing medical practice, demand that all must be done in the interest of the patient and, therefore, any and all medical records including the photographs, x-rays or whatever, must be available to ether the patient or to a physician of his/her choosing.

The reason to have the medical records at hand during the second opinion consultation is to understand the history and to see what the pre-operative state was and make a realistic judgment as to what could be reasonably achieved and what could not be achieved. It is also important to read the operative report to see if there are extending circumstances to compromise the result. Were there complications after surgery that had a bearing on the outcome? All these things are best understood by a thorough review of complete records.

You are entitled to have the best service possible. Don’t be shy. You are entitled to the records and you are entitled to the input from another doctor who may well say that the best was done that could be done. But in any event, you will feel better about hearing it from a second source.

Dr. 90210 Rhinoplasty Specialist

Posted on July 19, 2010 by admin

Dr. 90210 Rhinoplasty Specialist

Here, in Zip code 90210, there are some of the world’s most sophisticated cosmetic surgeons. “ The Golden Triangle of Beverly Hills, Zip 90210” has eye doctors who specialize in cosmetic surgery of the eyelids and brow and dermatologists who specialize in chemical skin peels and filler injections such as Juvéderm, Restylane, Perlane and of course, Botox and Dysport. We have other cosmetic plastic surgery specialists that have particular expertise in cosmetic breast surgery, both primary and revision breast augmentation. There is one surgeon whose practice is nearly only breast surgery and he does revision breast augmentation for patients who have had work done elsewhere and are dissatisfied.

Other cosmetic plastic surgeons specialize in tummy tuck and liposuction.

I have always felt that the most specialized and highly focused talents should be the choices for patients. Patients often don’t recognize or are unaware of the degree to which all medicine has become specialized, sub-specialized and superspecialized. A superspecialist is a doctor who practices a very boutique practice, focusing on six or fewer procedures. Typically, he has taken additional training beyond a long residency and even after passing the rigorous board exam to become “board certified”.

As one of the doctors who appeared on Dr. 90210 and as a rhinoplasty superspecialist, I can attest to the fact that, unfortunately, there are patients who come to see us who have had substandard work done by surgeons who have had very little training in cosmetic and functional nasal surgery, and who have no focus in that area. These surgeons may do everything from hair transplants to thigh implants and everything in between. Rarely will they be the most experienced and proficient practitioners.

What prospective patients need to know is that if they put themselves in the hands of those surgeons who have long experience and a fine degree of specialization, they are more likely to have a satisfactory outcome.

Rhinoplasty Costs in Hollywood

Posted on July 12, 2010 by admin

Rhinoplasty Costs in Hollywood

Do rhinoplasties cost more in Hollywood than in other parts of the country? I suspect they do. There are several reasons for this. One is that we do have more superspecialists here performing cosmetic procedures, including rhinoplasty. Superspecialists tend to command slightly greater fees because of their prominence, their excellence lower rate of re-do or revision surgery.

The cost of doing business is higher in Hollywood than it is in Lincoln, Nebraska or Appleton, Wisconsin. The labor costs are higher; nurses and surgical assistants command higher wages, all of which are a factor of the higher cost of living in California. Ditto for New York and other centers of excellence.

If one had blepharoplasty and chin augmentation he or she would expect to pay a bit more than you would elsewhere, although not greatly more than in other large cities that have very sophisticated practitioners of cosmetic plastic surgery including New York City, Miami and Houston.

When looking at costs in Hollywood or anywhere else, always be mindful to ask about “the entire cost.” You need to know what additional costs there would be for the outpatient surgery center, and anesthesia specialists, medications and perhaps even a postoperative recovery facility in which to stay for one or two nights.